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i
DEVELOPMENT AND VALIDATION OF MODEL OF AURAL
REHABILITATION OF PROFOUND HEARING IMPAIRED
CHILDREN IN PUNJAB - AN EXPERIMENTAL STUDY
Hina Noor
204/FUI/PHD(Edu)-2011
In partial fulfillment of the degree of
Doctor of Philosophy in Education
Foundation University
Rawalpindi campus
2017
ii
IN THE NAME OF ALLAH, THE MOST MERCIFUL
THE MOST BENIFICIENT
iii
DEDICATION
In
The memories of
My uncle
Syed Mansoor Ahmed
Dedicated to my lovely Children
Ayesha Imran & Muhammad Mustafa
iv
CERTIFICATE OF APPROVAL
This is certified that the research work presented in this thesis entitled
“Development and Validation of Aural Rehabilitation of Profound Hearing Impaired
Children in Punjab – An Experimental Study” was conducted by Mrs. Hina Noor
204/FUI/PHD(Edu-2011) – HEC Scholar under the supervision of M. Tayyab Ahmed
Bukhari. No part of this thesis has been submitted anywhere else for any other degree.
This thesis is submitted to the Department of Education of in partial fulfilment of the
requirement for the degree of Doctor of Philosophy in Field of Education, Department of
Education, Foundation University Rawalpindi Campus.
Student Name: Hina Noor Signature: _______________
Examination Commmittee
a. External Examiner 1: Dr. M. Imran Yousaf Signature: _______________
Director, Division of continuing Education,
Home Economics and Women Development,
PMAS Arid Agriculture University, Rawalpindi.
b. External Examiner 2: Dr. Saeed ul Hassan Chisti Signature: _______________
Director, Institute of professional Development
International Islamic University, Islamabad.
c. Internal Examiner: Dr. Mushtaq Ahmed Signature: _______________
HOD Education Department,
Foundation University Rawalpindi Campus.
Supervisor: Prof Dr. Raja Nasim Akhter Signature:__________________
Dean: Faculty of Social Sciences Signature:_______________
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AUTHOR’S DECLARATION
I Hina Noor hereby state that my PhD thesis titled “Development and Validation
of Aural Rehabilitation of Profound Hearing Impaired Children in Punjab – An
Experimental Study” is my own work and has not been submitted previously by me for
taking any degree from this Foundation University or anywhere else in the country/world.
At any time if my statement is found to be incorrect even after my Graduate, the
university has the right to withdraw my PhD degree.
_______________
HINA NOOR
Date: April 17, 2017
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PLAGIARISM UNDERTAKING
I solemnly declare that research work presented in the thesis titled “Development
and Validation of Aural Rehabilitation of Profound Hearing Impaired Children in
Punjab – An Experimental Study” is solely my research work with no significant
contribution from any other person. Small contribution/help wherever taken has been
duly acknowledged and that complete thesis has been written by me.
I understand the zero tolerance policy of the HEC and Foundation University
towards plagiarism. Therefore I as an Author of the above titled thesis declare that no
portion of my thesis has been plagiarized and any material used as reference is properly
referred/cited.
I undertake that if I am found guilty of any formal plagiarism in the above titled
thesis even after award of PhD degree, the University reserves the rights to
withdraw/revoke my PhD degree and that HEC and the University has the right to publish
my name on the HEC/University Website on which names of students are placed who
submitted plagiarized thesis.
Signature:______________
Name: HINA NOOR
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ACKNOWLEDGEMENT
First and foremost praises and thanks to Almighty Allah (Subhanahu Wa Taalaa)
for providing me this opportunity and granting me the capability to proceed successfully,
because of His showers of blessings throughout my research work. Peace and blessing of
Allah be upon last Prophet Muhammad (Peace Be upon Him).
I would like to thank the Higher Education Commission (HEC), Govt. of Pakistan
for providing funds under Indigenous Scholarship Scheme (085-10471-SS5-234).
I would like express my unrestrained appreciation to my thesis advisor for his
constant help and guidance. Thanks are also due to the former Dean FUCLAS Prof. Dr.
Maqsood Alam Bukhari and my co-supervisor Prof. Dr. Tahir Ahmed (ENT) for their
attention, cooperation, comments and constructive criticism.
Special thanks from the core of my heart are expressed here to Dr.Manzoor Arif
for his professional guidance, valuable support and constructive recommendations on this
project. He has been helping me out and supported me throughout the course of this work
and on several other occasions. I would like to express my deep gratitude to Dr. Shagufta
and the Audiologist Dr.Atif Ikram for their patient guidance, enthusiastic encouragement
and useful critiques of this research work.
I wish to thank the various people mentioned in the dissertation for their useful
comments about the Model and the tool of experimentation of this project and also to all
focal persons for their help in collecting the data. Special gratitude to the administration
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of the special education institution that provided me a space for conduction of
experimentation and also to the administration of mainstream education for allowing me
to take the speech perception tests of the children. All the technicians who helped me in
data analysis and editing of the dissertation are also acknowledged here.
I also acknowledge my colleagues, class fellows, friends, relatives, and others not
mentioned here, that helped me directly or indirectly throughout my research project.
Finally, I extend my acknowledgement and heartfelt love to my husband and
parents who have been with me all the time to spur my spirits.
HINA NOOR
204/FUI/PHD(Edu)-2011
HEC: (085-10471-SS5-234)
ix
TABLE OF CONTENTS
CERTIFICATE OF APPROVAL ...................................................................................... iv
AUTHOR’S DECLARATION ............................................................................................v
PLAGIARISM UNDERTAKING ..................................................................................... vi
TABLE OF CONTENTS ................................................................................................... ix
LIST OF TABLES ........................................................................................................... xix
LIST OF FIGURES .........................................................................................................xxv
ABSTRACT ................................................................................................................. xxviii
CHAPTER 1 ........................................................................................................................1
INTRODUCTION ...............................................................................................................1
1.1 STATEMENT OF THE PROBLEM .............................................................................7
1.2 OBJECTIVES OF THE STUDY ...................................................................................8
1.3 SIGNIFICANCE OF THE STUDY...............................................................................8
1.4 HYPOTHESES ..............................................................................................................9
1.5 DELIMITATIONS ......................................................................................................10
1.6 METHODOLOGY ......................................................................................................10
1.6.1 Population. ...............................................................................................10
1.6.2 Sample and Sampling Technique. ............................................................10
1.6.3 Research Design .......................................................................................11
1.6.4 Research Instruments ...............................................................................11
x
1.6.5 Collection of Data ....................................................................................12
1.6.6 Analysis of the Data .................................................................................12
CHAPTER 2 ......................................................................................................................14
REVIEW OF RELATED LITERATURE .........................................................................14
Part I ...................................................................................................................................14
HEARING IMPAIRMENT ...............................................................................................14
2.1 INTRODUCTION TO HEARING IMPAIRMENT ....................................................14
2.1.1 Anatomy and Physiology of Hearing .......................................................16
2.1.2 Types of Hearing Impairment ..................................................................17
2.1.2.1 Conductive hearing loss ......................................................................17
2.1.2.2 Sensorineural hearing loss ..................................................................17
2.1.2.3 Mixed hearing loss ..............................................................................18
2.1.3 Types according to degree of hearing loss ...............................................18
2.1.3.1 Usual Symptoms of Different Degrees of Hearing Loss ....................19
2.1.4 Types according to the extent of hearing loss ..........................................20
2.1.5 Types according to timings of loss...........................................................20
2.1.6 Causes of Hearing Impairment.................................................................21
2.1.6.1 Causes of conductive hearing loss ......................................................21
2.1.6.2 Causes of sensorineural hearing loss ..................................................22
2.1.7 Diagnosis of Hearing Loss .......................................................................23
2.1.7.1 Hearing Tests for the Newborn ...........................................................23
xi
2.1.7.2 Hearing Tests for the Infant ................................................................24
2.1.7.3 Hearing Tests for the Toddler .............................................................24
2.1.7.4 Hearing Tests for the Older Child ......................................................25
2.1.7.5 Hearing Test for Adult ........................................................................27
2.1.8 Impact of Hearing Impairment .................................................................28
2.1.9 Treatment for Hearing Loss .....................................................................29
2.1.10 Preventing Hearing Loss ........................................................................31
Part II .................................................................................................................................34
2.2 SPEECH PERCEPTION .............................................................................................34
2.2.1 Definition .................................................................................................34
2.2.2 The Nature of Speech Perception .............................................................35
2.2.2.1 Evidence .............................................................................................35
2.2.2.2 Knowledge ..........................................................................................35
2.2.2.3 Skills ...................................................................................................36
2.2.3 Development of Speech Perception: ........................................................36
2.2.4 Speech Perception Testing and Hearing Impairment ...............................42
2.2.5 Important Attributes of Speech Perception Test Development................46
2.2.5.1 Attributes Related to Item Selection of the Test: ................................47
2.2.5.2 Attributes of Test Recording and Presentation Method .....................52
2.2.5.3 Dependent Attributes of Speech Test .................................................56
Part III ................................................................................................................................61
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2.3 AURAL REHABILITATION .....................................................................................61
2.3.1 Rehabilitation Versus Habilitation ...........................................................61
2.3.2 Definition of Aural Rehabilitation ...........................................................61
2.3.3 Aural Versus Audiologic Rehabilitation ..................................................63
2.3.4 Services Included in Aural Rehabilitation ...............................................64
2.3.4.1 Identification and Evaluation of Sensory Capabilities .......................64
2.3.4.2 Interpretation of Results, Counselling and Referral ...........................64
2.3.4.3 Intervention for Communicative Difficulties .....................................65
2.3.5 Aural Rehabilitation and Auditory Training ............................................65
2.3.5.1 Fundamental Rules of Auditory Training ...........................................66
2.3.6 Aural Rehabilitation Strategies and Models ............................................67
2.3.6.1 A Clinical Overview of Communication (Re) Habilitation for the
Hearing Impaired By Susan H. Brainerd ........................................................67
2.3.6.2 Audiological Rehabilitation: Management Model by D.P. Goldstein
and S.G. D. G. Stephen (1981) .......................................................................72
2.3.6.3 Review of Different Curriculum Developed for Auditory Habilitation
of Deaf Children by Jane Freutel. ...................................................................75
2.3.6.4 Bally’s Aural Rehabilitation Model (1999) ........................................77
2.3.6.5 Aural Rehabilitation Directions Based on Massaro’s Model of
Information Processing. (Jay Lubinsky, 1986) ...............................................79
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2.3.6.6 Conversational Approach to Aural Rehabilitation by O.T. Kenworthy
(2002) ..............................................................................................................81
2.3.6.7 CORE/CARE Model for Audiologic Rehabilitation by Ronald L.
Schow (2001) ..................................................................................................84
2.3.7 Glimpses of Aural Rehabilitation in Different Countries ........................87
2.3.7.1 NEW ZEALAND ...............................................................................87
2.3.7.2 USA ....................................................................................................89
2.3.7.3 CHINA ................................................................................................93
2.3.7.4 VIETNAM ..........................................................................................94
2.3.7.5 TURKEY ............................................................................................99
2.3.7.6 INDIA .................................................................................................99
2.3.7.7 THAILAND ......................................................................................101
2.3.7.8 IRAN .................................................................................................102
2.3.7.9 PAKISTAN.......................................................................................103
2.3.7.10 Hearing Healthcare for Children in Developing Countries: ...........106
CHAPTER 3 ....................................................................................................................111
METHODOLOGY ..........................................................................................................111
3.1 SECTION A ...............................................................................................................112
3.1.1 POPULATION .......................................................................................112
3.1.2 SAMPLE ................................................................................................112
3.1.3 INSTRUMENTATION .........................................................................114
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3.1.4 DATA ANALYSIS ................................................................................115
3.2 SECTION B ...............................................................................................................116
3.2.1 DEVELOPMENT OF THE PROPOSED MODEL OF AURAL
REHABILITATION: ......................................................................................121
3.3 SECTION C ...............................................................................................................122
3.3.1 METHODOLOGY .................................................................................122
3.3.1.1 Detection: ..........................................................................................123
3.3.1.2 Discrimination ..................................................................................123
3.3.1.3 Identification .....................................................................................124
3.3.1.4 Comprehension .................................................................................128
3.3.2 DATA COLLECTION AND ANALYSIS ............................................131
3.3.2.1 Selection of Children for Pilot Test ..................................................131
3.3.2.2 Administrator of Test ........................................................................131
3.4 Section D ....................................................................................................................132
3.4.1 DESIGN OF THE EXPERIMENTAL RESEARCH .............................132
3.4.2 POPULATION .......................................................................................133
3.4.3 SAMPLE AND SAMPLING PROCEDURE ........................................133
3.4.3.1 Selection of a School ........................................................................133
3.4.3.2 Selection of the Children ..................................................................133
3.4.4 RESEARCH INSTRUMENT ................................................................134
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3.4.5 FORMATION OF CONTROL GROUP AND EXPERIMENTAL
GROUP ...........................................................................................................134
3.4.6 PREPARATION FOR THE TREATMENT .........................................135
3.4.7 METHODOLOGY OF EXPERIMENT: ...............................................136
3.4.8 COLLECTION AND ANALYSIS OF DATA ......................................137
CHAPTER 4 ....................................................................................................................139
PRESENTATION AND ANALYSIS OF DATA ...........................................................139
4.1 PART A .....................................................................................................................139
4.1.1 TEACHER’S QUESTIONNAIRE ........................................................140
4.1.1.1: Demographic Data: ..........................................................................140
4.1.1.2: Data Related to HIC ........................................................................143
4.1.1.3: Teaching Methodology and Teacher’s, Recommendations: ...........146
4.1.2 PARENT’S QUESTIONNAIRE ...........................................................150
4.1.2.1: Demographic Data: ..........................................................................150
4.1.2.2: Data About HIC’s Communication Level .......................................156
4.1.2.3: Data About Availability of Different Services to the Parents of HIC162
4.1.2.4 Parental satisfaction from available support from the professionals 175
4.1.3 SPEECH THERAPIST’S QUESTIONNAIRE......................................178
4.1.3.1: Demographic Data of SLT’s: ..........................................................178
4.1.3.2: Data of HIC: ....................................................................................179
4.1.3.3 Auditory profile of HIC ....................................................................181
xvi
4.1.3.4 practices of speech therapists ............................................................183
4.1.3.5: Provisions Available to SLTs: .........................................................184
4.1.4 PRINCIPAL’S QUESTIONNAIRE ......................................................187
4.1.4.1: Demographic Data ...........................................................................188
4.1.4.2: Data Regarding Available Provisions for Different Goals of
Educating HIC ..............................................................................................190
4.1.5 AUDIOLOGIST’S QUESTIONNAIRE ................................................197
4.1.5.1: Demographic Data ...........................................................................197
4.1.5.2 Available Provisions and practices of audiologist ............................199
4.1.5.3 Recommendations of the audiologist ................................................202
4.2 PART B ......................................................................................................................203
PROPOSED AURAL REHABILITATION MODEL .....................................................203
4.2.1 Assumption and Problem Statement ......................................................207
4.2.2 Resources ...............................................................................................207
4.2.3 Inputs ......................................................................................................208
4.2.4 Output .....................................................................................................209
4.2.5 Outcomes ...............................................................................................212
4.2.6 Impact Both intended and unintended system/community level changes
likely to occur are as follows: .........................................................................213
4.3 PART C ......................................................................................................................214
URDU SPEECH PERCEPTION TEST...........................................................................214
xvii
4.3.1 Establishment of reliability and validity of USPT .................................218
4.3.1.1 Construct Validity .............................................................................219
4.3.1.2 Split half reliability ..........................................................................220
4.3.1.3 Test-retest Reliability ........................................................................220
4.3.1.4 Inter-scorer Reliability ......................................................................221
4.4 PART D ......................................................................................................................222
EXPERIMENTAL SECTION .........................................................................................222
CHAPTER 5 ....................................................................................................................233
SUMMARY, FINDINGS, CONCLUSIONS, DISCUSSION AND
RECOMMENDATIONS .................................................................................................233
5.1 SUMMARY ...............................................................................................................233
5.2 FINDINGS .................................................................................................................235
5.2.1 Survey Questionnaires ...........................................................................235
5.2.2 CAR Model ............................................................................................243
5.2.3 Urdu Speech Perception Test .................................................................244
5.2.4 Experimental Validation ........................................................................245
5.3 DISCUSSION ............................................................................................................246
5.4 CONCLUSIONS........................................................................................................258
5.5 RECOMMENDATIONS ...........................................................................................262
5.5.1 Recommendations for Action ................................................................262
5.5.2 Recommendations for Future Researchers.............................................269
xviii
REFERENCES ................................................................................................................273
APPENDIX A ..................................................................................................................302
APPENDIX B ..................................................................................................................306
APPENDIX C ..................................................................................................................311
APPENDIX D ..................................................................................................................315
APPENDIX E ..................................................................................................................321
APPENDIX F...................................................................................................................326
APPENDIX G ..................................................................................................................328
APPENDIX H ..................................................................................................................329
APPENDIX I ...................................................................................................................332
APPENDIX J ...................................................................................................................337
APPENDIX K ..................................................................................................................340
APPENDIX L ..................................................................................................................346
APPENDIX M .................................................................................................................347
APPENDIX N ..................................................................................................................353
APPENDIX O ..................................................................................................................360
APPENDIX P...................................................................................................................362
APPENDIX Q ..................................................................................................................364
APPENDIX R ..................................................................................................................365
xix
LIST OF TABLES
Table 1: Degree of Hearing Loss .......................................................................................18
Table 2: Sampling Distribution of the Institutions ..........................................................113
Table 3: Sample Size distribution ....................................................................................113
Table 4: Comparison of Phonemic and Phonetic Analysis of Urdu Speech Samples .....126
Table 5: Attributes of Urdu Speech Perception Test .......................................................130
Table 6: The response Rate of Each Questionnaire .........................................................139
Table 7: The Age and Gender of the Teachers of HIC ....................................................140
Table 8: Qualification and the Post Held by the Teachers ...............................................141
Table 9: Experience and Professional Qualification of the Teachers ..............................142
Table 10: Ages and Degree of Hearing Loss of HIC .......................................................143
Table 11: Provision and Type of Hearing Aid of HIC .....................................................144
Table 12: Usage and Comfortability of HIC with Hearing Aid .......................................144
Table 13: Speech Therapy and Communication Level of HIC ........................................145
Table 14: Sign Language Skills of HIC and their Teachers ............................................146
Table 15: HIC’s Ability to Understand Specific Topic when Communicated by only
Speech or only Signs ........................................................................................................147
Table 16: Current Mode of the Communication during Teaching and Teacher’s
Recommendations ............................................................................................................148
Table 17: Teachers’ Recommendations about the Special Needs of HIC .......................149
Table 18: HIC’s Class and Age Group ............................................................................150
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Table 19: Gender and Disability other than Hearing Impairment of the HIC and Incidence
of Hearing Impairment in Family ....................................................................................151
Table 20: Educational Level of the Parents of HIC .........................................................152
Table 21: Professional Level of the Parents of HIC ........................................................153
Table 22: Number of Siblings and Monthly Income of the HIC Family .........................154
Table 23: When did the Child Become Deaf and When was he Diagnosed as Deaf? .....155
Table 24: Mother Tongue and Other Languages Used at the Home of HIC ...................156
Table 25: Imitation Skills and Receptive Language of HIC ............................................157
Table 26: Receptive Language Skills of the HIC ............................................................157
Table 27: Correct Responses to Yes/ No and What/Where/When/Why Questions by HIC158
Table 28: How Well HIC Could Communicate with the Parents? ..................................159
Table 29: How Well HIC Could Communicate with the Siblings? .................................160
Table 30: How Well HIC Could Communicate with the Teacher and Others? ...............161
Table 31: Availability of Services of Different Professionals in the Last Six Months....162
Table 32: HIC’s Parental Demand of Recent Contact with Whom? ...............................163
Table 33: Availability of Support from Doctors When Deafness was Diagnosed ..........164
Table 34: Availability of Support from the Teachers and Psychologist When Deafness
Was Diagnosed ................................................................................................................165
Table 35: Availability of the Support from Educational Audiologists and Speech
Therapists When Deafness Was Diagnosed ....................................................................166
xxi
Table 36: Availability of the Support from Family and Any Other Person, When
Deafness Was Diagnosed .................................................................................................167
Table 37: Availability of the Support from Social Case Worker, When Deafness Was
Diagnosed and Parental Views about HIC Needs Neglected by Hospitals/ Schools ......168
Table 38: Parental Wish to Have Availability of the Support from Different Professionals
at the Time of Diagnosis ..................................................................................................169
Table 39: Availability of the Support from Doctors During Primary School Years of the
HIC ...................................................................................................................................170
Table 40: Availability of the Support from the Teachers and Psychologist During Primary
School Years of HIC ........................................................................................................171
Table 41: Availability of the Support from Educational Audiologists and Speech
Therapists During Primary School Years of HIC ............................................................172
Table 42: Availability of the Support from Family and Any Volunteer, During Primary
School Years of HIC ........................................................................................................173
Table 43: Availability of Support from Social Case Worker, During Primary School
Years of HIC and Child’s Academic Progress in School ................................................174
Table 44: Parental Wish to Have Availability of the Support from Different
Professionals, During Primary School Years of HIC ......................................................175
Table 45: Summary of Parental Opinion about Problems Faced by them and Areas,
Demanding Immediate Attention from the Government .................................................176
xxii
Table 46: Summary of the Parental comments about current system and
recommendations .............................................................................................................177
Table 47: Age, Gender and Employment Status of the Speech Therapist .......................178
Table 48: Educational level and Experience of the Speech Therapist .............................179
Table 49: Age Group of HIC and Provision of the Speech Therapy Sessions per Week 179
Table 50: Provision of the Hearing aid, Hearing Aid Type and Use of Aid by HIC .......180
Table 51: The Listening Skills of the HIC .......................................................................181
Table 52: Identification of Speech Sounds and Comprehension of Connected Words by
the HIC .............................................................................................................................182
Table 53: Diagnosis of Speech, Language and Listening Skills of the HIC....................183
Table 54: Record Keeping by the Speech Therapist ........................................................184
Table 55: Available Provisions to the Speech Therapists ................................................185
Table 56: Analysis of the Prevailing Situation and Recommendations by SLTs about
Future Needs ....................................................................................................................186
Table 57: Age and Gender of the Principals ....................................................................188
Table 58: Experience and the Nature of Employment of the Principal ...........................189
Table 59: Provisions for Academic Development of HIC ...............................................190
Table 60: Provisions for Vocational Development of HIC .............................................191
Table 61: Provisions for Speech and Language Development of HIC ............................192
Table 62: Provisions for Co-curricular Development of the HIC ....................................194
Table 63: Provisions for Physical and Emotional Health and Development ...................195
xxiii
Table 64: Provisions for Aural Rehabilitation, Mainstreaming and Professional
Development of the Staff .................................................................................................196
Table 65: Age, Gender and Professional Qualification of the Audiologist .....................197
Table 66: Experience and Nature of Employment of the Audiologists ...........................198
Table 67: Provisions, Available to the Audiologists .......................................................199
Table 68: Determination of the Nature and Degree of Hearing Loss ..............................200
Table 69: The Provision of Different Intervention Services by the Audiologists to the
HIC ...................................................................................................................................201
Table 70: Prevailing Situation and the Future Needs as Recommended by the
Audiologists .....................................................................................................................202
Table 71: Mean Frequency of Occurrence of Urdu Consonants .....................................214
Table 72: Mean Frequency of Occurrence of Urdu Consonants .....................................215
Table 73: Frequency distribution of Speech Perception Raw Scores of Normally Hearing
Children with Percentile Ranks and z Scores ..................................................................216
Table 74: Frequency distribution of Speech Perception Raw Scores of hearing impaired
children with their Percentile Ranks and z Scores ...........................................................217
Table 75: Mean and S.D of Pretest Speech Perception Scores of Control Group and
Experimental Group .........................................................................................................222
Table 76: Significance of the Difference between Mean Pretest Speech Perception Scores
of Control Group and Experimental Group .....................................................................223
xxiv
Table 77: Mean and S.D of Posttest Speech Perception Scores of Control Group and
Experimental Group .........................................................................................................223
Table 78: Significance of the Difference between Mean Posttest Speech Perception
Scores of Control Group and Experimental Group..........................................................224
Table 79: Significance of the Difference between Mean Pretest, Posttest Speech
Perception Scores of the Control Group ..........................................................................225
Table 80: Significance of the Difference between Mean Pretest, Posttest Speech
Perception Scores of the Experimental Group .................................................................226
Table 81: Age wise Mean and S.D of Pretest Speech Perception Scores of the Control
Group and the Experimental Group .................................................................................227
Table 82: Significance of the Difference between Mean Pretest Speech Perception Scores
of the Younger and Older HIC of Control Group and Experimental Group ...................228
Table 83: Age wise Mean and S.D of Posttest Speech Perception Scores of Control
Group and Experimental Group .......................................................................................229
Table 84: Significance of the Difference between Mean Posttest Speech Perception
Scores of the Younger and Older HIC of Control Group and Experimental Group........230
Table 85: Significance of the Difference between Mean Pre- Posttest Speech Perception
Scores of HIC Boys and Girls of the Control Group .......................................................231
Table 86: Significance of the Difference between Mean Pre- Posttest Speech Perception
Scores of the HIC Boys and Girls of the Experimental Group ........................................232
xxv
LIST OF FIGURES
Figure 1: Attributes of a speech Test Materials .................................................................47
Figure 2: AR Service Plan by Tye Murray (2009) ............................................................63
Figure 3: Audiological Rehabilitation Management Model 1 ...........................................73
Figure 4: Bally's Model ......................................................................................................77
Figure 5: A model of Information Processing by Massaro ................................................79
Figure 6: CORE and CARE Model of Aural Rehabilitation .............................................85
Figure 7:Summarized View of the Recommendations of the Stakeholders ....................203
Figure 8: Coding of the models against five basic components of a model ....................204
Figure 9: CAR Model for HIC in Pakistan .................................................................206
Figure 10: Predictive Validity of Urdu Speech Perception Test......................................218
Figure 11: Construct validity of Urdu Speech Perception Test .......................................219
xxvi
ABBREVIATIONS
AR Aural Rehabilitation
A.V Audio Visual
ASHA American Speech and Hearing Association
ASLP Audiology Speech Language Pathologist
B. A Bachelors in Arts
BERA Brain Stem Evoked Response Audiometry
B. Ed Bachelors in Education
B.T.E Behind the Ear
CAR Comprehensive Aural Rehabilitation
D.G Director General
ENT Ear, Nose and Throat
e. g. For example
H.aid Hearing aid
HATs Hearing Assistance Technology
HEC Higher Education Commission
H. I Hearing Impaired
HIC Hearing Impaired Children
ICWs Information Carrying Words
ITEIP Infant and Toddler Early Intervention Programme
xxvii
i. e. that is
IEP Individualised Education Plan
M. A Masters in Arts
M. Ed Masters in Education
M. Phil Master’s in philosophy
M. Sc Masters in Science
NIRM National Institute of Rehabilitation Medicine
NSEC National Special Education Centre
NTCSP National Training Centre For Special Persons
PBK Phonetically Balanced
PTM Parent teacher Meeting
Ph. D Doctor of Philosophy
Rwp Rawalpindi
S. D Standard Deviation
SLT Speech Language Therapist
SNR Signal to Noise ratio
USPT Urdu Speech Perception Test
WHO World Health Organisation
xxviii
ABSTRACT
Persons with hearing loss have been seen, but the problems and frustration
imposed by this loss in their lives have not been imagined. Only diagnosis of hearing loss
and providing amplification is not enough to ensure the development of communication
potentials of the hearing impaired children (HIC). Aural habilitation/rehabilitation
services for children are the dire need of all those suffering from hearing loss, especially
for those having severe and profound hearing loss. In Pakistan the rehabilitative plans
merely cover speech therapy and special education services employing sign language and
total communication as a medium of instruction. The efforts are not being focused on
auditory development of the children, which is the base of all problems of HIC.
Therefore, the researcher aimed to target this entirely neglected area of provision of aural
rehabilitation services through a model in order to bring change in the lives of HIC in
Pakistan.
The objectives of the study were to collect data about current provisions of aural
rehabilitation for hearing impaired children in Punjab, to develop a model of aural
rehabilitation for deaf children in Pakistan, to develop a standardised tool to be used
during experimentation and to validate the proposed model of aural rehabilitation via
experimentation. The study carries immense significance from different angles in the
context of the planning and management of educational cum rehabilitative plans of
children with hearing loss. The model may serve as a guide to policy makers,
administrators of special schools, speech therapists, teachers and parents.
xxix
The design of the study was the pretest-posttest control group design. Sample
groups were selected through random sampling technique. Data regarding current
rehabilitation practices was obtained through questionnaires for teachers, speech
therapists, audiologists, principals and parents of HIC. A framework of the proposed
model was made with the help of logic model development guide and by incorporating
the recommendations of the stakeholders obtained via questionnaires. Pakistani experts’
opinions were obtained through questionnaire for further modification required in the
model. The model was validated through experimentation. A speech perception test was
developed and its reliability and validity were established after conducting a pilot study.
This test was used as the tool of experimentation i.e. to obtain the pretest and posttest
scores of the HIC. The difference in mean speech perception scores of the control group
and experimental group profound HIC at posttest level was significant at 0.01 level. It
was concluded that aural rehabilitation is feasible as well as necessary for educational
and vocational rehabilitation of HIC in Pakistan. Multidisciplinary approach in special
schools to be served as preparatory schools for mainstreaming, provision of digital
hearing aids from government, auditory training, integrated curriculum development,
follow-up of IEP’s focusing on aural mode of communication, development of
assessment tools in national and regional languages, efforts for screening and prevention
of hearing loss and parental training cum involvement in planning and implementation of
individual plans were considered as the necessary ingredients, to bring change in current
educational cum aural rehabilitation programme of HIC in Punjab.
1
CHAPTER 1
INTRODUCTION
Rehabilitation is a process of physical restoration of a sick or disabled person
through therapeutic measures and re-education to participate in the activities of a normal
life within the limitation of physical disability of the person. There is no universally
accepted definition or theoretical model to describe rehabilitation. The king’s fund (2000)
in Scotland has produced a working definition of rehabilitation, which describes it as “A
process aiming to restore personal anatomy to those aspects of daily life considered most
relevant by patient or service users, and their family careers.”
A more detailed analysis of rehabilitation, which relates more to the specialist’s
role and focuses on structure, process and outcomes is provided by Wade & De Jong
(2000) He presented the structure of rehabilitation as consisting of a multidisciplinary
team of people having relevant skill and knowledge and involved in re-education of
patient and family. They work together towards common goals for each patient and can
resolve most of the patient’s common problems. The process of rehabilitation has the
components of assessment of the patient's problems, goal setting and providing
interventions which maintains the patient's quality of life and his or her safety and finally
the evaluation of these interventions. The outcomes outlined are to maximise the
participation of the patient in his or her society and minimise the pain and distress
experienced by the patient and the patient's family.
2
These definitions and analysis have stressed a patient focused approach to
rehabilitation journey and have emphasised that to place rehabilitation at the heart of a
service, we need to move away from reactive, unplanned episodic approach towards
rehabilitation to reiterate, active, educational, problem solving process focused on a
patient's behaviour (disability). Evidence shows that intensive ongoing and personalised
case management can improve the quality of life and outcomes for individuals.
Individuals and their care takers consider that quality of life is about more than the ability
to perform basic activities of daily living, commonly a central focus of rehabilitation,
especially in the early phase. The ability to perform basic activities is of course
important, but is secondary to the need to enable social engagement and purposeful
occupation, which is the key to encouraging a sense of self-worth and well-being. In case
of HIC, the success rate in social engagement and purposeful occupation is extremely
dependent on the communication potentials of the individuals which are revived through
AR.
Aural rehabilitation is a process of identifying and diagnosing a hearing loss,
implementing different amplification devices to aid the client’s hearing abilities and
providing different type of therapies, for example, speech and language development,
auditory training to the client (hearing impaired person). Auditory training is defined as a
process of teaching an individual with hearing loss the ability to recognise speech sounds,
patterns, words, phrases and sentences via audition. It is frequently used as an integral
component in the overall management of the individual with hearing loss and refers to
3
services and procedures for facilitating adequate receptive and expressive communication
in hearing impaired individuals. There are two major types of auditory training.
Auditory/oral training not only stresses auditory training, but also trains a child to use
speech reading and contextual clues to receive information. Children that have
auditory/oral training tend to pick up signs as a second language so that they can
communicate with signing peers. The auditory/Verbal training only trains the child to use
his residual hearing. Children that have a successful training tend to be completely
mainstreamed into hearing society (Erber, 1978). Factors that might affect therapeutic
outcomes in audiology/aural rehabilitation are the degree of hearing loss, age of onset of
loss affecting behavioural and linguistic needs of the individual, differences demanding
individual or group therapy approaches, socioeconomic status determining capacity to
purchase available products and services and the culture influencing interaction between
hearing impaired individual and practitioner (Tye Murray, 2014).
All the above mentioned factors need to be given due consideration in model
development. Different models of aural rehabilitation are being developed and presented,
highlighting the importance of these variables. Sander (1982) offers a management model
of aural rehabilitation. He presented a specific problem solving approach in which the
most important factor is relevance; which is achieved by understanding the unique
deleterious effect hearing loss has on an individual’s total behaviour. His model proceeds
in a logical sequence from an analysis of human communication system through the
intervention strategies designed for maximising the use of residual capacities of hearing
4
impaired individuals. Bally (1999) introduced a model of aural rehabilitation that
illustrates how the diagnosis and rehabilitative aspects of audiologic management can be
merged. The model shows the multiple components and various levels of interactions
involved in contemporary audiometric and aural rehabilitative processes.
Kochkin (2005) discussed the impact of treated hearing loss on quality of life. He
cited the research by the National Council on the Ageing on more than 2000 people with
hearing loss and other significant persons attached to them and demonstrated that hearing
aids are clearly associated with impressive improvements in social, emotional,
psychological and physical well-being of people with hearing loss from mild to severe
categories. In children, the most debilitating effect of hearing loss is disruption to learn
speech and language. The combination of early detection and early use of amplification
has been shown to have a dramatically positive effect on the language acquisition
abilities of a child with hearing loss. In fact, infants identified with a hearing loss by 6
months can be expected to attain language development on par with hearing peers.
Durkel (2003) discussed the importance of including auditory training in the curriculum
of deaf blind students. He offered some suggestions for activities and resources related to
providing auditory training. The resources, he mentioned, include auditory Skills
Instructional Planning System, Speech Perception Instructional Curriculum and
Evaluation, Developmental Approach to Successful Listening, Cottage Acquisition
Scales for Listening, Language and Speech, Cochlear Implant, Auditory and Tactile
Skills Curriculum etc.
5
Once hearing loss has been identified, it is essential that the person becomes
informed of all the options available to help improve his communication. There is a
common misconception that hearing aids are the “cure all” for hearing loss. In reality,
improving communication involves a long term rehabilitation process in which the
hearing aid is only a part. As such, the person should enter into this rehabilitation process
with realistic goals and knowing what to expect from the hearing aid. Hearing aids are
powerful, effective tools for increasing ability to hear. But hearing aids will not
automatically make one a better listener. Listening requires attention, concentration and
interest. Often people with hearing losses develop poor listening skills. This occurs
because hearing becomes so difficult that they give up and just “turn off” the speaker.
The majority of severe to profound hearing impaired student in Pakistani special schools
either are not provided with hearing aids and those who have it are not prone to use it for
the same reason. Once hearing aids are fitted, it is imperative that the child’s listening
skills are re-sharpened and it is done by auditory training of that person. The training is a
means by which children with significant hearing loss are taught how to hear, how to
listen, how to understand the language of normally hearing persons and how to
effectively speak the same language. As a result the deaf child is no longer relegated to a
world of silence and illiteracy.
The Pakistan Cochlear Implant Programme was started in the year 2000. One
hundred and fifty subjects have so far undergone cochlear implant surgery during the
period from 2001 to 2007 at three centres, namely Karachi, Lahore and Peshawar. The
6
goal of the study by Mukhtar et al. (2008) was to evaluate auditory perception skill
development in children over a period of twelve months following cochlear implantation.
Results suggested that cochlear implanted children develop speech recognition soon after
implantation and these skills develop over a long period of time, highlighting the need for
continued therapy to maximise listening and learning.
In Pakistan, the situation is bad due to lack of awareness and is becoming worse
due to lack of aural rehabilitation provisions in special schools. Even at the ministry
level, no such attention towards the provision of auditory training is available due to the
extreme shortage of educational audiologists. Speech and Language therapy is provided
to children, but the prevailing atmosphere of sign language and lack of training of
teachers regarding auditory training is a great hindrance in getting long lasting effects in
speech, language and auditory skill development of HIC. In addition, even the trained and
experienced special education teachers are unaware of the contemporary educational
practices for HIC all around the world e.g. different international curricula integrating
auditory training practices. The HIC, whose parents can afford private speech therapy and
auditory training practices are successfully mainstreamed, but still the ratio of such
students is very low.
The prevailing conditions in Pakistan clearly demonstrate the need of a
rehabilitation model for development of aural rehabilitation of majority of deaf students
going to special schools. Thus the researcher aimed at the development of such model
which might help to make plans at the administrative level and may help the school
7
management team to make a timetable of effective rehabilitation process involving
auditory training method and proposed schedule of action that can facilitate deaf child’s
inclusive education targets.
1.1 STATEMENT OF THE PROBLEM
Nations including Pakistan has collectively committed to Salamanca statement
(1994) that “The practice of ‘mainstreaming’ children with disabilities should be an
integral part of national plans for achieving education for all” (p.18). But the current
scenario of segregated education system of Pakistan without any legal support for
compulsory mainstreaming is the main impediment on the achievement of the goal. The
target cannot be achieved unless we follow another statement that “Barriers that impede
movement from special to regular schools should be removed and a common
administrative structure organized” (p.19).
In case of HIC the most prominent barrier, in addition to lack of mainstreaming
act, is their communication handicap which seriously affects their social, educational and
vocational success in life. Moreover the rehabilitation practices working in separate
domains, i.e. medical rehabilitation and educational rehabilitation, are against the
phenomenon of “common administrative structure organized”. The result is that in
present circumstances the academic, communication and vocational needs of hearing
impaired children are not effectively met by the current education system of HIC in
Pakistan. An integrated system of aural rehabilitation is required for effective social,
educational and vocational mainstreaming of HIC in our society. The special education
8
centers present in every tehsil of Punjab can be utilized effectively if held responsible to
initiate and coordinate the rehabilitation practices from screening to mainstreaming of
HIC.
1.2 OBJECTIVES OF THE STUDY
The main objectives of the study were:-
• To critically appraise education cum rehabilitation provisions for children with
hearing impairment in Punjab.
• To design a model of aural rehabilitation for children with hearing impairment.
• To develop and validate the tool of experimentation.
• To validate the aural rehabilitation model via experimentation.
1.3 SIGNIFICANCE OF THE STUDY
The research is entitled as development of model of aural rehabilitation for
profound hearing impaired children in a school setting. The main purpose of selecting the
topic was that no such model exists in Pakistan upon which foundations of aural
rehabilitation of HIC could be based in accordance with available resources. The model
was developed in accordance with the developments made in the rehabilitation of the
deaf community in foreign advanced countries as well as after incorporating the
recommendations made by the stakeholders involved in aural rehabilitation process. Thus
the model would be an example of modern rehabilitation services provided to the deaf
community in the context of provisions available in Pakistan.
9
The results of this research would be significant in drawing attention of Pakistani
special education teachers towards the different models of aural rehabilitation and need
for development of integrated auditory training curricula. It might serve as a value able
source of highlighting the leadership expected from the special education
centers/institutions. The results will help in alleviating the burden of parents for social,
educational and vocational rehabilitation of their hearing impaired children. It will be a
guide to special education policy makers, curriculum developers, rehabilitation
specialists, educational practitioners, administrators, and speech and language therapists
etc. to remove the barriers for mainstreaming of HIC in the community. To sum up, the
results of this study are expected to be beneficial for all those involved in rehabilitation of
HIC directly or indirectly. The model is likely to serve as a guide to all inclusive and
special education schools of Pakistan.
1.4 HYPOTHESES
Following null hypotheses were tested with the help of the experiment.
H01: There is no significant difference between the mean speech perception scores of
experimental and control group children before the experiment.
H02: There is no significant difference between the mean speech perception scores of the
control and experimental group after the experiment.
H03: There is no significant difference between the mean pre and post speech perception
test scores of the control group children.
10
H04: There is no significant difference between the mean pre and post speech perception
test scores of experimental group children.
1.5 DELIMITATIONS
The section of experiment in research was delimited to:-
1. Hearing impaired children with 90 dB or above hearing loss
2. Children with age group 4-14 years old
3. Government Special Schools for Deaf in Punjab
4. HIC provided with post aural, digital hearing aids.
1.6 METHODOLOGY
1.6.1 Population.
All special educational institutions (35) for HIC and special education centers
(126) catering HIC in addition to other three disabilities, run by the Punjab Directorate of
Special Education, constituted the population of the study. For experimentation purpose
only, all public special education schools (10) of Rawalpindi were taken as the
population.
1.6.2 Sample and Sampling Technique.
Two stage cluster sampling was done to select the sample for the study. 27
institutions were randomly selected through first stage cluster sampling in such a way
that one higher secondary school, one secondary/middle school and one centre dealing
with four major disabilities was selected from nine divisions of Punjab. There were three
11
degree colleges for deaf in Punjab. All were taken as a sample to make a total of thirty
institutions. During second stage of cluster sampling, survey questionnaires were given to
randomly selected 20-30 parents of HIC, 10-15 teachers from institutes and 2-3 from
centers and to the SLT, audiologist and principal of each institution. One special school
from Rawalpindi was selected for experimental treatment on the basis of availability of
the highest number of profound HIC of 4-14 years age, provided with bilateral digital
hearing aids.
1.6.3 Research Design
Pretest-posttest control group design was selected as a suitable design for
experimental validation of the model. Experimental treatment of auditory training was
independent variable and speech perception test scores of HIC was the dependent
variable of the experiment.
1.6.4 Research Instruments
1. Data regarding current rehabilitation practices was obtained through self
developed five questionnaires for teachers, parents, SLTs, audiologist and
principal.
2. A framework of the proposed model was prepared and opinions of experts
in the field of rehabilitation were obtained through a questionnaire.
3. A speech perception test covering the areas of auditory skills, i.e.
detection, discrimination, identification and comprehension was prepared. A
Questionnaire was prepared to check familiarity of words from fifteen native
12
Urdu speakers belonging to different districts of Punjab. A questionnaire was
prepared to check the content validity of the proposed test. Validity and reliability
were established after conducting a pilot study.
1.6.5 Collection of Data
Data was collected in four stages:
1. Data of a survey of existing rehabilitation provisions was obtained via
mailed questionnaires.
2. Data regarding the development of the model was obtained in the form of
recommendations of stakeholders through survey questionnaires. Moreover the
common elements of international models of AR were incorporated after
evaluating the models against the criteria outlined in the Logic Model
Development Guide.
3. Data related to establishing the reliability and validity of the Urdu Speech
Perception Test was obtained after the conduct of the pilot study.
4. Data regarding validation of the proposed model consisted of pretest
scores of sample groups. The experimental group was provided training for four
weeks, according to the structure of the model. Again the posttest scores of both
groups were obtained.
1.6.6 Analysis of the Data
1. Data collected through survey questionnaires were analyzed by calculating
simple percentages.
13
2. Qualitative data collected through survey questionnaires and model of
aural rehabilitation were analyzed by NVivo 11 pro.
3. Data collected for tool development and validation were analyzed by
calculating simple percentages, frequencies, raw scores, percentile ranks and
standard scores.
4. t-test was used to find the significance of difference between the scores of
experimental and control group. The level of significance was 0.05.
14
CHAPTER 2
REVIEW OF RELATED LITERATURE
This chapter deals with the review of related literature and the discussion has been
divided into three parts.
Part I: Hearing impairment
Part II: Speech perception
Part III: Aural rehabilitation
Part I
HEARING IMPAIRMENT
2.1 INTRODUCTION TO HEARING IMPAIRMENT
According to Dorland Medical Dictionary (2011) for Health Consumers,
impairment is the loss or reduction of any body part or natural activity of human.
International Classification of Functioning, Disability and Health (ICF: WHO, 2001) has
defined disabilities as an umbrella term covering impairments, activity limitations, and
participation restrictions. Thus, it is a complex phenomenon, reflecting an interaction
between features of a person’s body and the society in which he or she lives. Hearing
impairment refers to complete or partial loss of the ability to hear from one or both ears.
The level of impairment can be mild, moderate, severe or profound, whereas deafness
refers to complete loss of ability to hear from one or both ears. Hearing impairment is an
inability to perceive sounds due to any defect in the sense of hearing. According to Farlex
15
Partner Medical Dictionary (2012), hearing impairment is referred to as malfunctioning
or reduction in hearing ability as a result of which person’s hearing is partially or totally
affected and he may not hear normally i.e. perceive the incoming sound stimuli. Due to
loss or reduction in hearing, person’s communication abilities also suffer a lot. Hearing
impairment is a generic term that is used for both hard of hearing and totally deaf
individuals. This impairment can be in the whole auditory spectrum or in the region
between 250 and 4,000 Hz.
According to Global Burden of Disease 2000 project, hearing impairment is
considered to be most frequently occurring sensory organ deficit in human population.
Nearly 250 million people get affected by hearing loss in the world. Olusanya (2012)
quoted that out of 122.9 million babies born in developing countries, about 6 per 1000
births are likely to have permanent congenital or early onset hearing loss as compared to
2 per 1000 live births in developed countries. Strawbridge et al. (2000) and Yoshinaga
Itano etc. al. (1998) quoted that hearing impaired individuals often feel difficulty in
communication in addition to this; they face difficulty in perceiving sound. Due to their
handicap they are isolated from the society, feel problems in education among children
and economic problems in adult individuals. The condition is worsened when a hearing
impaired person is also suffering from diabetes mellitus or other medical complications.
Loss (2011) and Yu, C. et. al. (2003) reported that most congenital and childhood
onset hearing loss are the consequences of various disease and injury causes, including
otitis media, meningitis, rubella, congenital anomalies and non-syndromal inherited
16
hearing loss. The leading causes of adult-onset hearing loss are presbycusis (age related
hearing loss) followed by noise-induced hearing loss.
2.1.1 Anatomy and Physiology of Hearing
The organ of sound, human ear is an important organ as it perceives and
differentiates between different sounds ranging from the low leaves rustling to the loud
roaring sound of a fighter jet plane. The process of hearing is a step by step process
where one part of the ear sends the sound signals to the next part so that an individual can
perceive the sound signals. This process can be easily understood if the ear is divided into
three parts, namely a) outer ear, b) middle ear and c) the inner ear.
Sound waves enter the outer ear, which consists of the outer visible part of the
ear, in addition to the ear canal. Sound waves pass through the outer ear canal and strike
the tympanic membrane or ear drum of the middle ear. The vibrations in the tympanic
membrane amplify the sound waves and send them to the group of three bones named as
ossicles of the ear. Then the amplified sound enters into the inner ear, consisting of
semicircular canals and cochlea. The fluid and tiny hair like cells present in the cochlea
amplifies the sound again. This step by step amplification is very important as it allows
the human ear to hear the sound as low as that of whispering or humming sound of birds.
The hair like cells of the inner ear then translates the sound waves into electrical nerve
impulses and sends them to the brain by the help of auditory nerves. The brain interprets
these nerve impulses and we are able to listen and understand the sound striking our ear.
(Northern & Downs, 2002) The process of hearing seems very long but in reality it
17
happens almost instantly. A sound waves strike your ear drum (tympanic membrane) and
you interpret it almost immediately. If there is any problem in any part of the ear the
hearing ability is distorted and the person may become completely deaf of partially
hearing impaired.
2.1.2 Types of Hearing Impairment
Hearing impairment is usually categorised depending on the specific reasons due
to which the auditory system is not working properly.
2.1.2.1 Conductive hearing loss
Conductive hearing loss occurs when there is a problem with the conduction of sound
signals in the middle ear. This problem can be in the eardrum, ear canal or ossicles. This
type of hearing loss mainly involves reduction in sound perception or inability to hear
faint sounds. Causes of conductive hearing loss can be blocked due to the presence of any
foreign particle in the ear canal, infections in the ear canal, tumours or any presence of
fluid in the middle ear. These consequences show that this hearing loss can be treated
surgically or by medications, for example, removal of foreign body or treatment of
infections and tumours in the middle ear (Raz, 2004).
2.1.2.2 Sensorineural hearing loss
Sensorineural hearing loss is a type of hearing loss resulting from the damage in the inner
ear, particularly cochlea or the auditory nerve (8th cranial nerve). The most common
factor of sensorineural hearing loss is when in cochlea the outer hair cells are not
functioning correctly. This is a permanent type of hearing loss in which the victim feels
18
difficulty in hearing properly and he is unable to interpret various sounds. Therefore the
only remedy against this is the use of hearing aids (Bansal, 2012).
2.1.2.3 Mixed hearing loss
A combination of both conductive and sensorineural hearing loss is called as mixed
hearing loss.
2.1.3 Types according to degree of hearing loss
Severity of hearing impairment implies to the degree or grade of hearing loss. The World
Health Organisation has classified hearing impaired individuals on the basis the range of
hearing loss in decibels (dB HL). They have categorised hearing impairment in five
categories according to the threshold level ranging from “no impairment” to “profound
impairment” The level of severity of hearing loss defined by Clark (1981) is as follows:
Table 1: Degree of Hearing Loss
10-15 dB HL Normal Hearing
16-25 dB HL Slight Hearing Loss
26-40 dB HL Mild Hearing Loss
41-55 dB HL Moderate Hearing Loss
56-70 dB HL Moderate-Severe Hearing Loss
71-90 dB HL Severe Hearing Loss
>90 dB HL Profound Hearing Loss
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2.1.3.1 Usual Symptoms of Different Degrees of Hearing Loss
2.1.3.1.1 Profound hearing loss
Profound hearing loss is the most extreme hearing loss. A profound hearing loss
means that you may not hear loud speech or any speech at all. You are forced to rely on
visual cues instead of hearing as your main method of communication. This may include
sign language and/or speech reading (also commonly referred to as "lip reading").
2.1.3.1.2 Severe hearing loss
People with severe hearing loss have difficulty hearing in all situations. Speech
may be heard only if the speaker is talking loudly or at close range. A severe hearing loss
may sometimes cause you to miss up to 100% of the speech signal. Symptoms of severe
hearing loss include inability to have conversations except under the most ideal
circumstances (i.e. face-to-face, in quiet, and accompanied with speech reading).
2.1.3.1.3 Moderate hearing loss
A moderate hearing loss may cause you to miss 50-75% of the speech signal. This
means you would not have problems hearing at short distances and understanding people
face-to-face, but you would have problems if distance or visual cues changed. Symptoms
of moderate hearing loss include problems hearing normal conversations and problems
hearing consonants in words.
20
2.1.3.1.4 Mild hearing loss
A mild hearing loss may cause you to miss 25-40% of the speech signal. Usually
this results in problems with clarity since the brain is receiving some sounds, but not all
of the information. Symptoms of mild hearing loss include problems understanding
someone farther away than at normal distance for conversation, or even close if the
background environment is noisy. Weak voices are also difficult to understand for people
with mild hearing losses.
2.1.4 Types according to the extent of hearing loss
The degree of hearing impairment can vary widely from person to person. Some
people have partial hearing loss, meaning that the ear can pick up some sounds; others
have complete hearing loss, meaning that the ear cannot hear at all (people with complete
hearing loss are considered deaf). In some types of hearing loss, a person can have much
more trouble when there is background noise. One or both ears may be affected called
unilateral and bilateral hearing loss respectively, and the impairment may be worse in one
ear than in the other one.
2.1.5 Types according to timings of loss
The timing of the hearing loss can vary, too. Congenital hearing loss is present at
birth. Acquired hearing loss happens later in life — during childhood, the teen years, or
in adulthood — and it can be sudden or progressive (happening slowly over time). If the
hearing loss occurs before speech and language development, it is termed as pre-lingual
21
and if it occurs after the child has attained speech and language development fully, it is
termed as post-lingual hearing loss.
2.1.6 Causes of Hearing Impairment
The causes can be divided into two sections:
2.1.6.1 Causes of conductive hearing loss
Conductive hearing loss can be due to a number of causes ranging from normal
infection to complete dis-functioning of any part or whole auditory pathway. Among
them, one of the leading causes of most hearing problems is any infection. The infection
due to any pathogenic organism can cause accumulation of fluid in the outer and middle
ear that may block sound signals entering the ear. In medical terms for infection of the
middle ear, causing hearing impairment is otitis media (Bluestone et al., 1992; Rovers et
al., 2004). The treatment of otitis media is the usage of antimicrobial drugs. Fortunately,
once the infection gets better the patient may hear normally, therefore we can say that it
is a curable hearing impairment in children and teens.
Apart from infections, blockage may also be due to a physical blockage in the form of
any foreign body in the ear, fluid due to cold, and deposition of earwax due to any reason
inside the ear. These types of blockages can cause conductive hearing loss in all age
groups. In addition, people often get conductive hearing loss when key parts of the ear —
the eardrum, ear canal, or ossicles — are damaged. For example, a tear or hole in the
eardrum can interfere with its ability to vibrate properly. The causes of this damage may
include inserting an object such as a cotton swab too far into the ear, a sudden explosion
22
or other loud noise, a sudden change in air pressure, a head injury, or repeated ear
infections.
2.1.6.2 Causes of sensorineural hearing loss
Sensorineural hearing that is due to inner ear’s damage can be due to a number of
causes like genetic disorder, pregnancy complications, head injuries, noise, infections,
and medications including chemotherapy drugs.
A newborn can be hearing impaired if there was some complication in pregnancy.
These complications hinder the normal development of the ear and thus babies are highly
prone to hearing impairment. A baby can also be hearing impaired if he is inheriting any
genetic disorder related to hearing that can affect the normal development of auditory
nerve or inner ear. Diseases and infections like measles, mumps, chickenpox, smallpox
and tumours may also be damaging for ear structures. While treating these disorders and
other problems the medications and treatments that involve antibiotics and chemotherapy
may also be a causing factor of hearing impairment not only in children but even in
adults.
Last but not the least; the noise is another factor that can cause damage to hair like
cells in the cochlea. The loud noise is really very much damaging for cochlea and when
the cochlea is damaged, the sound may not be transmitted. Therefore, it can be said that
continuous exposure to loud noise can not only damage hair like cells in cochlea but it
can also damage the auditory nerve.
23
2.1.7 Diagnosis of Hearing Loss
There are many different types of hearing tests that can be used to check hearing.
Some of them may be used on all ages, while others are used based on your child's age
and level of understanding.
2.1.7.1 Hearing Tests for the Newborn
There are two primary types of hearing screening methods for newborns. These
may be used alone or together.
2.1.7.1.1 Otoacoustic emission testing (OAE)
Otoacoustic emission is the first sound emitted by the inner ear. The research
shows that if the inner ear is affected, these sounds are absent. Therefore, Otoacoustic
emissions are used for testing inner ear health. In this test, a tiny and flexible plug is sent
to the inner ear. By the help of this plug sounds are sent. The Otoacoustic emissions are
emitted from the inner ear are then recorded with the help of a microphone device. If a
baby has some damage in the inner ear, no sound is recorded with the microphone, and
then the baby is sent to audiologist for further testing and treatment. In this way the first
screening is done in a painless way (Kemp, 1978).
2.1.7.1.2 Automated auditory brainstem response
Automated audiometry brainstem response (ABR) is a neurological test used for
audiometry testing. The audiometric transducer is the form of earphone that is inserted
into the baby’s ear. This transducer sends test sounds in baby’s ear. By the help of Band-
Aid like electrodes a sensing device is attached to ear lobes or baby’s scalp. These
24
electrodes detect how the auditory nerves respond to these sounds to test baby’s hearing
loss (Mehl & Thomson, 1998).
If the first screening test identifies a child’s hearing ability to be affected, the baby is
subjected to further testing. The further testing should be done as soon as possible so that
till he baby is of 3 months, he can be identified as hearing impaired and his treatment can
be started timely, without any delay.
2.1.7.2 Hearing Tests for the Infant
Evaluation of hearing in the infant may also include the tests that are applied to
newborns in addition to behavioural audiometric screening as infant have developed
some sense of response to sound signals. If parents notice that the infant is not responding
to the loud sounds and voices, the physician may perform an initial behavioural screening
test to check the presence of natural reflexes to the loud sounds e.g. eye blink, startle
reflex. After this test further screening and diagnostic testing is required.
2.1.7.3 Hearing Tests for the Toddler
Evaluation of hearing may include the above mentioned tests, along with the following:
2.1.7.3.1 Play audiometry
Play audiometry is a hearing test designed for children from 3 to 5 years in which
an electrical machine sends sound signals of different volumes and different pitches in
the child’s ear. On hearing sound, a child is asked to touch a toy, raise his hand or
perform any action of the child’s interest. This test needs high cooperation from the
child’s side and modification in test is required to suit the child’s age.
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2.1.7.3.2 Visual reinforcement audiometry (VRA)
This test is based on a reward system where the child is trained to look towards a
sound source. When the child gives a correct response, the child is "rewarded" through a
visual reinforcement such as a toy that moves or a flashing light. This test is most often
used for children between six months to two years.
2.1.7.4 Hearing Tests for the Older Child
For children above three years of age, the hearing tests can be any test explained
above or few other tests that are specially designed for older children. The tests,
especially for older children are as follows.
2.1.7.4.1 Pure Tone Audiometry
In pure tone audiometry, sound signals are sent to the child’s ear through an
audiometric device with the help of headphones. These sounds are of different volumes
and at varying pitches. Upon hearing sound, an older kid is asked to respond in any way
like by pressing the button or raising his hand. At this age the system of reward is
generally not used.
2.1.7.4.2 Tympanometry
Tympanometry, that is also called impedance audiometry is a test used to test the
working of the middle part of the ear. This test cannot tell about hearing impairment in
children, but it can tell about any change in pressure of the middle ear and also about the
working of bones of the middle ear (Steele et al, 2003). A machine called as
tympanogram is placed in the ear that changes pressure in the ear to move the ear drum.
26
The movements are recorded in the form of an audiograph on the tympanogram machine.
Due to its sensitivity this test cannot be applied to younger children as a child is required
to sit still without any movement or noise.
2.1.7.4.3 Acoustic reflex test
Acoustic reflex test is the test mostly performed in older children. This test is
named as acoustic reflex test as it checks the reflex of a muscle in the middle ear that
responds to high intensity sound, when an audiologist places a probe in the ear and a loud
tone (mostly greater than 70 dB) is produced. If acoustic muscles do not respond to this
loud voice, the person is diagnosed as hearing impaired (Timothy & Hain, 2014).
2.1.7.4.4 Speech perception test
The test is also known as speech discrimination test or speech audiometry. It
involves testing a child’s ability to hear words without using any visual information. The
words may be played through headphones or a speaker, or spoken by the tester.
Sometimes, the child is asked to listen to the speech sounds in the presence of a
controlled level of background noise (speech in noise testing).
2.1.7.4.5 Impedance tympanometry
Impedance tympanometry measures the ‘impedance’ of sound by the eardrum.
The eardrum should ideally allow as much sound as possible to pass into the middle ear.
If sound is reflected back from the eardrum, hearing will be impaired (or impeded). Fluid
in the middle ear will impede sound. During impedance tympanometry, a small tube will
27
be placed at the entrance of your child’s ear and air will be gently blown down into their
ear. The test can be used to confirm whether your child has glue ear.
2.1.7.5 Hearing Test for Adult
In addition to speech perception test, pure tone audiometry and tympanometry,
following test of hearing can be used for diagnosis.
2.1.7.5.1 Whispered voice test
The whispered voice test is a very simple hearing test. Any doctor or practicing
nurse, while blocking one of your ears, can test hearing by whispering words at varying
volumes. Patient is asked to repeat the words loudly as he/she hears them.
2.1.7.5.2 Tuning fork test
A tuning fork produces sound waves at a fixed pitch when it is gently tapped. To
test hearing, the tester will tap the tuning fork on the elbow or knee to make it vibrate,
before holding it at each side of your head in turn. At first, the tuning fork will be held in
the air, next to the ear, and then against the bone behind the ear (the mastoid bone). This
is called a Rinne test and it can help to determine whether there is a middle ear
(conductive) or inner ear (sensori-neural) pattern of deafness. The tuning fork can also be
placed on the centre of forehead or on the bridge of nose. Whether the sound is heard in
the good or bad hearing ear, it can also help to distinguish between the two types of
hearing loss. This is known as a Weber test.
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2.1.7.5.3 Bone conduction test
A bone conduction test is often carried out as part of a routine pure tone
audiometry test, although it may not be suitable for very young children. It involves
placing a vibrating probe against the mastoid bone behind the ear. It tests how well
sounds that are transmitted through the bone are heard. Bone conduction is a more
sophisticated version of the tuning fork test, and when used together with PTA through
headphones (air conduction), it can help to determine whether hearing loss comes from
the outer and middle ear, the inner ear, or both.
2.1.8 Impact of Hearing Impairment
Hearing loss is considered as the dilemma which leads to the social problems like
hesitation and prejudice. Impact of hearing loss, on the lives of people varies with the
change in degree of hearing loss. People having hearing impairment have to suffer a lot
functionally, economically, emotionally and socially as people consider them abnormal
and ignore them. We have groups of such people in our society who make fun of these
people. Communication is a basic skill cum necessity of life. Any person having any
problem related to communication will lag behind in the social race and will have
reduced quality of life. So is the case of hearing impaired persons, as one of the main
functional impacts of hearing loss is in the individual’s ability to communicate with
others. Figueras (2008) quoted a delay in spoken language development of profoundly
deaf children when compared with that of their hearing counterparts. Rout et al. (2008)
reported a variety of academic and adjustment problems of children with hearing loss in
29
schools. Yoshinaga Itano (2001) reported the importance of early detection and
intervention in minimising the effects of hearing loss and leading to significant
improvements in social and educational achievements of the child.
The second most debilitating effect of hearing loss on individuals is on their
economic status. According to the O’Keefe, P. (2007) about disabilities in India,
unemployment rates of disabled persons, including hearing loss in India are much higher
than normal people. Moreover, even employed ones belong to lower skill level jobs.
Ruben (2001) reported that hearing loss affects not only the individuals, but social and
economic development of the country is also affected.
Social and emotional impacts of hearing loss are seen in every age group of HIC and
especially for teens and elderly people. Hearing loss can have a significant impact on
everyday life, as reported by Ciorba et al (2012) resulting in feelings of loneliness,
isolation, frustration and dependence. Hearing loss is reported to restrict activities such as
going to the market alone or visiting friends. However, it is important to understand that
people with hearing loss can do everything except hear normally.
2.1.9 Treatment for Hearing Loss
Treatment for hearing loss varies.
• Treatment for temporary or reversible hearing loss usually depends on the cause
of the hearing loss. It is often treated successfully. For people with conductive hearing
loss there is often the possibility of improving their hearing with an operation or a device
such as a Bone Anchored Hearing Aid (BAHA). ENT surgeon who will diagnose the
30
cause and offer treatment. Hearing loss caused by ototoxic medicines (such as aspirin or
ibuprofen) often improves after stopping the medicine. An ear infection, such as a middle
ear infection, often clears up on its own, but may need antibiotics. An injury to the ear or
head may heal on its own, or may need surgery. Otosclerosis, acoustic neuroma, or
Maniere's disease may require medication or surgery. An autoimmune problem may be
treated with corticosteroid medicines, generally prednisone. Ear wax is treated by
removing the wax.
• Treatment for permanent hearing loss includes using hearing devices or hearing
implants. Hearing aids come in various forms that fit inside or behind the ear and make
sound louder. They are adjusted by the audiologist so that the sound coming in is
amplified enough, to allow the person with a hearing impairment to hear it clearly. They
do not restore the hearing, but they may help to communicate more easily. Having
occasional hearing tests can help to know when the hearing aids need adjustment.
Sometimes, the hearing loss is so severe that the most powerful hearing aids can't
amplify the sound enough. In those cases, a cochlear implant may be recommended.
Cochlear implants are surgically implanted devices that bypass the damaged inner ear
and send signals directly to the auditory nerve. A small microphone behind the ear picks
up sound waves and sends them to a receiver that has been placed under the scalp. This
receiver then transmits impulses directly to the auditory nerve. These signals are
perceived as sound and allow the person to hear. Several types of hearing implants are
31
available, each for specific types of hearing problems. Some implants require devices to
be worn outside the ear. Newer implants are contained within the ear.
Assistive listening devices, alerting devices, and other communication aids are
also helpful. Although permanent hearing loss is viewed as part of ageing, but still proper
treatment is important. Hearing loss may contribute to loneliness, depression, and loss of
independence. Treatment cannot bring back the hearing, but it can make communication,
social interaction, and work and daily activities easier and more enjoyable. Depending
upon whether someone is born without hearing (congenital deafness) or loses hearing
later in life (after learning to hear and speak, which is known as post-lingual deafness),
medical professionals will determine how much therapy the person needs to learn to use
an implant effectively. Many people with implants learn to hear sounds effectively and
even use the telephone. More than 200,000 people around the world have received
cochlear implants and about one third of them are children.
Some patients with hearing loss and their families may decide not to restore
hearing. This is particularly true of children whose parents are hearing impaired and want
their children to be able to function in the deaf community. The language of the deaf
community is a sign language which is a system of gestures, many deaf and hearing
impaired people use to communicate.
2.1.10 Preventing Hearing Loss
Hearing loss can be prevented at three levels as reported by Smith (2002).
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1. Primary prevention of the causes of hearing loss and ear disease can be achieved
by means such as better antenatal and prenatal care, immunisation, rational use of
ototoxic drugs and hearing conservation programmes for prevention of noise-induced
hearing loss.
2. Effective management at the secondary prevention level includes the early
detection and treatment of ear diseases such as chronic otitis media. Screening is now
regarded as an essential tool for the early detection of childhood hearing loss. In 1995,
the 48th World Health Assembly adopted a Resolution regarding the preparation and
implementation of national programmes for early detection, prevention and control of
major avoidable causes of hearing loss in babies and toddlers. World report on disability
(2011) emphasised that screening programmes must be approached as social change.
Olusanya (2000) recommended that the programme should also target to bring change in
attitudes, beliefs and perceptions about hearing loss. Some of the reported common
misbeliefs about ear diseases and hearing loss are as follows.
• Causes of hearing loss are bewitchment, result of impurity in the blood, the curse
of ancestral spirit (Swanepoel and Almec, 2008).
• Srikanth et al. (2009) mentioned that home remedies are considered to be an
effective care of earache or infection.
• Hearing impairment cannot be cured. However Brobby (1998) quoted that 50% of
all causes of hearing loss can be prevented.
33
3. Tertiary prevention refers to the management and rehabilitation of hearing loss
and includes the provision of good-quality hearing aids, essential support services, access
to appropriate communication, improvements in the acoustic environment, special
education and social integration at all levels. In low- and middle-income countries as
reported in the WHO guidelines (2004), it is estimated that only 3% people in need of
hearing aid are provided so due to the high cost of hearing aids, cost of maintenance and
use of aids and the stigma associated with using the aid. Limited government resources
and a global decline in grants and donations from the high-income countries of the world
to developing countries are other important reasons.
The intensity of sound is measured in units called decibels, and any sounds over
80 decibels are considered hazardous with prolonged exposure. These include sounds like
loud sirens and engines and power tools such as jackhammers and leaf blowers. To
reduce the risk of permanent hearing damage, one can turn down the volume of stereo,
TV, and especially the headset of music player. Wear earplugs if one is going to a loud
concert or other event. Special protective earmuffs are a good idea while operating a lawn
mower or leaf or snow blower, or at a particularly loud event like a car race (Cotton in
the ear doesn't provide enough protection).
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Part II
2.2 SPEECH PERCEPTION
2.2.1 Definition
Hearing is a way to perceive the vibrations caused by sounds. Perception is not a
just mode of hearing, it is how to sound is interpreted and made sense of. This same
sound can be perceived differently by two listeners. Borden and Harris (1980) define
speech perception as a process of decoding a message from a stream of sounds coming
from the speaker. Boothroyd (1991) defined speech perception as a process by which a
perceiver internally generates linguistics structures believed to correspond with those
generated by a talker. Massaro (2001) quoted speech perception as “the process of
imposing a meaningful perceptual experience on an otherwise meaningless speech input”.
Andrew and Lotto (2004) defined speech perception as “perceptual mapping from the
highly variable acoustic speech signal to a linguistic representation, whether it be
phonemes, di-phones, syllables, or words”. Houston (2012) described speech perception
as a mode of hearing specialised for speech. Speech perception refers to how an
individual understands, what a listener is saying and he can differentiate between the
phonetics, words and syllables uttered by the speaker. Broadly speaking, it refers to how
an individual understands what others are saying. Specifically, it is the way a listener can
interpret the sounds produced by any speaker as a sequence of discrete linguistic
35
categories such as phonemes, syllables or words. In other words, the process by which
sounds of language are heard, interpreted and understood is known as speech perception.
2.2.2 The Nature of Speech Perception
Speech perception is a complex process involving the integration of several
components divided into three major groups i.e. evidence, knowledge and skills.
2.2.2.1 Evidence
• Sensory evidence of speech is gained mainly by the perceiver’s ears and also
with eyes, especially for hearing impaired persons.
• Linguistic contextual evidence is provided in the shape of phonetic, lexical,
syntactic, and semantic elements with the help of the surrounding language patterns i.e.
meaningful words (Boothroyd and Nittrouer, 1988). Words are easily recognised in
sentences (Miller, Heise and Lichten, 1958) and sentences are in a paragraph or
conversation (Hnath-Chisolm, Hanin and Boothroyd, 1985).
• Unlike linguistic context, situational contextual evidence is equally available to
normally hearing as well as H. I individuals. It includes objects, people, events, and even
the surrounding space. It alters the relative probability of choosing the possible
interpretations of any spoken message.
2.2.2.2 Knowledge
• Knowledge about language includes the knowledge of relationships among
speech movements and sounds (phonetics), the sound patterns and how they modify
the meanings (phonology), vocabulary, ways of expressing in form of sentences
36
(syntax), ways to express meanings (semantics) and ways to satisfy the intent of
language use (pragmatics).
• Knowledge about objects, events, attributes and rules of the surrounding physical
world affect the meanings of the spoken message thus affecting the perception.
• Similarly, knowledge of special attributes of people and the way, people use
language to satisfy their communication intent also affects the perception of the subjects.
2.2.2.3 Skills
Decision making is critical, as having knowledge is of no use unless it is used by
a perceiver to make choices among all possible interpretations of the sensory input.
• Speed is an important factor as the perceiver must make a decision on an equal or
exceeding rate of the incoming information without losing the accuracy. But main control
of speed is in the hands of the speaker rather than the perceiver.
• Speech perception is multitasking as it involves extracting meanings, deducing
significance and formulating a response at a same time. This important aspect has been
ignored in test development.
2.2.3 Development of Speech Perception:
Some researchers like K. Mori et. al. (2006) have proposed that infants may be
able to learn the sound categories of their native language through passive listening, using
a process called statistical learning. Others even claim that certain sound categories are
innate and are genetically specified. If a day-old babies presented with their mothers'
voices speaking normally, abnormally (monotone) and a strange voice, they react only to
37
their mother’s voice speaking normally. When a human and non-human sound is played,
babies turn their head only to the human sound. Thus auditory learning begins already in
the prenatal period. Bertoncini et al. (1988) investigated whether infants who listened to a
set of CV syllables noticed when a new syllable was added to the set. They used the high
amplitude sucking paradigm. They manipulated “how different” the added syllable was.
It could be just like the old syllables except that it contained a vowel that wasn’t in the
old syllable, or that it contained a consonant that wasn’t in the old syllable. The results
showed that the newborn heard the “big” change (vowel) but not the most subtle change
(consonant). By 2 months, though infants responded to all types of changes and one
would predict that at least for the first six months of age, one would see continued
improvement in the detailed representation of speech as infant’s basic auditory capacities
mature.
Infants begin the process of language acquisition by being able to detect very
small differences between speech sounds. They can discriminate all possible speech
contrasts (phonemes). Gradually, as they are exposed to their native language, their
perception becomes language specific, i.e. they learn how to ignore the difference within
phonemic categories of the language and focus more on contrasts between different
categories. This phenomenon is known as categorical perception. As infants learn how to
sort incoming speech sounds into categories, ignoring irrelevant differences and
reinforcing the contrastive ones, their perception becomes categorical. Infants learn to
contrast different vowel phonemes of their native language by approximately 6 months of
38
age. The native consonantal contrast is acquired by 11 or 12 months of age. The sucking
rate and the head turn methods are some of the more traditional behavioural methods for
studying speech perception; near-infrared spectroscopy is widely used in infants.
It has also been discovered that even though the infant’s ability to distinguish
between different phonetic properties of various languages begins to decline around the
age of nine months, it is possible to reverse this process by exposing them to a new
language in a sufficient way. In a research study by Kuhl (2003) and others, it was
discovered that infants are spoken to and interacted with by a native speaker of Mandarin
Chinese, they can actually be conditioned to retain their ability to distinguish different
speech sounds within Mandarin that are very different from speech sounds found within
the English language. Thus proving that, given the right conditions, it is possible to
prevent infant’s loss of ability to distinguish speech sounds in languages other than those
found in native language.
Jusczyk (1993) and his colleagues carried out a long series of experiments and got
the following results:
• Every young infant seems to be sensitive to some type of information in speech.
4.5 months old are able to pick out their names from ongoing speech, but it is not until six
months that they can pick out mommy and daddy. True word segmentation begins around
7. 5 months. They also notice if a pause in a sentence comes in the middle of a clause
instead of at the end of the clause.
39
• By eight months, infants show evidence of learning that certain combinations of
speech sounds occur together, even if they only hear the sounds several times a few
minutes.
• By nine months, infants seem to recognise the phonetic and stress patterns of their
native speech and they use this information in segmenting words, and they remember
words that occur in speech.
• By 10.5 months, infants use allophonic information to segment words.
• By 10-12 months, it seems to be an important time for native language learning.
• By 12 months, they seem to be able to several segmentation cues together.
• By the end of infancy, children seem to know a lot about speech.
Finally Hazen and Barrett (2000) examined the performance of school aged
children in speech discrimination and come up with the interpretation that the children
are less flexible in the way they process speech, adults can switch from one cue to
another if they need to do, but children don’t seem to be able to switch cues as needed.
One theory of how speech is perceived is the Motor Theory of speech perception
(Liberman, Cooper, Shankweiler & Studdert-Kennedy, 1967). The Motor Theory
postulates that speech is perceived by reference to how it is produced; that is, when
perceiving speech, listeners access their own knowledge of how phonemes are
articulated. Articulatory gestures such as rounding or pressing the lips together are units
of perception that directly provide the listener with phonetic information. Harry McGur
& MacDonald (1976) were interested in whether auditory or visual modalities are
40
differentially dominant during infants' perceptual development. To find out, they asked
their technician to create a film to test which modality captured infants' attention. In this
film, an actor pronounced the syllable "ga" while an auditory "ba" was dubbed over the
tape. Would babies pay attention to the "ga" or the "ba"? The process of making the film,
however, led to a surprising finding about adults. The technician (and others) did not
perceive either a "ga" or a "ba". Rather, the technician perceived a "da".
The process of speech perception is not necessarily unidirectional. That is a
higher level language processes connected with morphology, syntax or semantics may
interact with speech perception processes to aid in recognition of speech sounds. It may
be the case that it is not necessary and may be even not possible for a listener to recognise
phonemes before recognising higher units like words. After obtaining a fundamental
piece of information about the phonemic structure of the perceived entity from the
acoustic signal, listeners can compensate for missing or noise-masked phonemes using
their knowledge of the spoken language as shown in a classic experiment by Warren
(1970). He replaced one phoneme of a word with a cough like sound. His subjects
restored the missing speech sounds perceptually without any difficulty and could not
accurately identify which phoneme had been disturbed. This is known as the phonemic
restoration effect.
Another basic experiment compares recognition of naturally spoken words
presented in a sentence or at least a phrase, and the same words presented in isolation.
Perception accuracy usually drops in later condition. Games and Bond (1976) also used
41
carrier sentences when researching the influence of semantic knowledge on perception.
They created series of words differing only in one phoneme (bay/day/gay). The quality of
the first phoneme changed along the continuum. All the stimuli were put into different
sentences each of which made sense with one of the words only. Listeners had the
tendency to judge the ambiguous words, according to the meaning of the whole sentence.
The results of a study by Werker and Tees (1993) demonstrated the role of
experience in maintaining the perception of a contrast. They used the conditioned head
turn technique to test discrimination and found that 6-8 months old responded to a change
in non-native syllable, a high proportion of the time. 8-10 month old responded a little
less often and 10-12 months old hardly responded at all. Thus, between 6-12 months
children stopped making this discrimination. Later researches showed that:
• Sometimes 12-months old lose the non-native discrimination, but adults are able
to discriminate.
• Sometimes the non-native discrimination seems un-affected by the experience.
• The role of experience seems to be to reorganise perception in a way that makes it
hard to discriminate non-native contrasts.
• With the right kind of experience, adult listeners can learn to make non-native
discrimination.
It can now be easily concluded that it takes a long time for speech perception to
become as sensitive, complete and flexible as what is seen in adults. And that there is a
critical period during which experiences of hearing must occur in order for it to be
42
effective. The speech perception abilities will diminish quickly when stimulation is
absent. Recent researches have focused on finding the relationship between early speech
perception skills and later language abilities. Initial longitudinal studies in which
typically develop children have been tested at six months and then followed until their
second year, indicated a strong association between early speech perception and later
language development (Tsao et al., 2004). Moreover retrospective studies show that
measures taken at birth can be used to sort children between 3-8 years of age, with regard
to normal verses low language skills (Molfese, 1997, 2000). Finally, as viewed, when
children with the variety of impairments that involve language are compared to age-
matured controls, measures of speech perception shows that children with language
related difficulties also have significant deficits in speech perception (Reed, 1989;
Leonard et al., 1992 and Bradlow et al., 1999).
2.2.4 Speech Perception Testing and Hearing Impairment
Speech Perception is making inferences about language patterns (Phonemes,
words, phrases and sentences) represented by the speech of a talker. (Boothroyd, 1993b),
Impact of hearing loss on an individual depends on the extent to which speech perception
is affected. Boothroyd (1988a) considered the improvement in speech perception as the
primary goal of management. Thus, approaches include use of hearing aids or other
sensory aids, increased access to sound and rehabilitation plans to improve speech
perception skills in addition to educational intervention. He insisted on the importance of
speech perception test development, to get information about individual’s speech
43
perception capacity and performance, for effective selection, planning, implementation
and evaluation of these approaches.
Although phonetic learning can be affected by experiences of childhood, phonetic
learning exhibits the two principles cited by Knudsen (2004) for a critical period.
• A lack of exposure early in development to natural language, speech or sign
results in lack of normal language.
• Early experience with the particular language has indelible effects on speech
perception, meaning experience is required for learning to occur and learning produces
durable effect.
According to Kuhl et al. (2005), infant’s early phonetic perception predicted
language at many levels, e.g. number of words produced, the degree of sentence
complexity and the mean length of utterance. Tsao et al. (2004) concluded that speech
perception in infancy predicts language development in the second year of life. Knudsen
(2004) cited the presence of sensitive period during development of brain and behaviour.
Infant brain responses to speech suggest a phonetic level “critical period” mechanism
(Kuhl et al., 2005). The conclusion made by Medrerake (2012) stressed on the early
speech perception skill development, as previously identified language facilitating factors
of early identification of hearing impairment and early educational intervention has not
proved to be sufficient for optimising spoken language development of profoundly deaf
children, unless it leads to early cochlear implantation. The result of the study by Hidley
44
(2009) demonstrated that children are able to obtain additional benefits using hearing
instruments with increased bandwidth and binaural compression.
The most obvious consequence of pre-lingual hearing loss is a decrease in the
access to sound. Without maximal audibility, higher centres of auditory processing may
receive speech stimuli devoid of important phonemic cues that contribute to speech
understanding and language development. Even with optimum audibility, distortion of
input may further affect recognition and comprehension. Development of spoken
language for children with hearing loss requires the fitting of sensory devices, followed
by a well designed habilitation plan. Now we have tools to identify hearing loss at birth
and to fit sensory devices soon hereafter. However, we are limited in a standardised
behaviour test, required to assess auditory perceptual performance. The information
required to assess higher level auditory processing and to appraise intervention outcomes
depends on speech perception data. This data, in combination with speech and language
outcomes, are essential for establishing guidelines for habilitation.
Goal of auditory practice is to assist HIC in maximising auditory performance to
enable them to participate fully in every aspect of daily life. We have reached the goal or
not can be guided only by assessing the abilities of HIC to hear in different listening
conditions. Without testing, we cannot know what the person can and cannot hear
(ASHA 1984). According to ASHA, Aural rehabilitation is the thorough evaluation for
accurate and most commonly used effective diagnoses. Sound stimuli are pure tones and
speech pure tones, they provide information regarding the sensitivity, but not on the
45
receptive auditory ability. According to Lyregaard (1976) Speech audiometry means any
method of assessing the state or ability of an auditory system of an individual using
speech stimuli or sounds as a response evoking stimulus. Different kinds of material have
been developed by different investigators but speech materials need to be linguistically
appropriate for the person being tested which means that age, language, cognitive level,
level of complexity of material and competing noises present in the environment should
be given due importance before and during testing. In English language there are
numerous speech and word recognition test serving the following purposes:
• Assess the degree of hearing handicap as is relates to communication ability.
• Determine the site of lesion.
• To determine the need for, and to monitor the progress in aural (re)habilitation.
• To compare the hearing aid performance and assess the benefits of technology.
• To monitor patients' performance over time.
• To confirm tonal thresholds.
• To assess the ability to perceive and discriminate speech information.
• To plan and monitor habitation needs.
• To identify perception problems, which develop over time.
• For assessing the appropriate educational environment.
As it was difficult and not appropriate to assess the hearing abilities of any person
whose language is not English, thus attempts to develop tests in non-English languages
such as Spanish (Christensen, 1995), Portuguese (Haris & Goffa, 2001), Mandarin
46
Chinese (Nissen & Haris, 2005), Russian (Haris & Nissen, 2007),Tongan (Seaver, 2008),
Swedish (McAllister and Brodda, 2002), Cantonese (Van Haselt et al., 2003), Arabic
(Kishon-Rabin L. and Rosen house J., 2000) and Standardised speech audiometric
materials and tests in Indian Languages e.g. PB word list in English (Swarnalatha, 1972),
PB word list in Hindi (De, 1973), PB word list in Tamil (Dayalan, 1976), PB word list in
Manipuri (Devi, 1985), PB word list in Kannada (Yathiraj, 2005), PB word list in Mizo
(Mangaiahi, 2009), PB word list in Rajasthani (Kholia, 2010), PB word list in Telugu
(Kumar and Mohanty, 2012) and Ilocano PB word recognition test (Sagon, R. 2006) had
been made.
It has been proved by the researchers that accuracy of test results depends upon
familiarity or subject’s knowledge of the test material. According to Canhart (1951)
testing in non-native language may yield inaccurately low scores. Test materials in every
language should be developed and standardised in an experimental setting. Currently no
known speech test in Urdu language has been developed to check the hearing abilities of
individuals. The next section is devoted to the description of important considerations to
be kept in mind before and during development of any speech perception test.
2.2.5 Important Attributes of Speech Perception Test Development
Attributes of speech test material can be divided into three groups:
• Attributes which are implicit in item selection to comprise the test.
• Attributes related to recording and presentation of test material.
• Attributes that are the consequences of the first two types of attributes.
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Self developed summarised view of all these attributes is given in the figure 1.
Figure 1: Attributes of a speech Test Materials
2.2.5.1 Attributes Related to Item Selection of the Test:
2.2.5.1.1 Context
Context means knowledge of the world in which we communicate and knowledge
of language (phonological, syntactic and semantic rules). Speech perception test
comprising of nonsense syllables, has negligible contextual information, e.g. Ling seven
sound test (Ling, 1976), whereas words, sentences and paragraphs contain phonological
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and lexical information of varying degree. Examples of speech perception tests consisting
of words are CNC wordlist of Peterson and Lehiste (1963) and mono-syllabic trochee-
spondee test by Erber and Alencewicz (1976). SPIN test by Kalikow et al. (1977) contain
sentences with high or low predictability.
2.2.5.1.2 Acoustic Cues
A material rich in contextual cues is used to check language knowledge of the
subject, but materials with low contextual cues are basically used to check acoustic cues.
Acoustic cues at acoustic level are the fundamental frequency, formant frequencies or
amplitude of the test stimuli, whereas at the phonetic level of these is the presence of
specific vowels and consonants like stops, fricatives, glides, nasals etc. in the test
material.
All phonetic contrasts are cued by acoustic cues, e.g. successful vowel
discrimination in “key” and “car” may be done due to intensity difference only rather
than difference in formant structures or vowel quality. Similarity voicing distinction for
stops is marked by timing, burst intensity, presence of aspiration, first formant onset
frequency (initial position) and duration of preceding vowel (final position) etc. Subject
can discriminate speech on the basis of one feature only without benefit of the entire
range of features. The richness of the acoustic context of test items is related to phonetic
context firstly and secondly to the way it is recorded. Carefully designed and controlled
synthetic speech, closely modelled on natural speech, may be used to test perception of
major acoustic cues (Hazon and Fourcin, 1985). The same carrier phase in which it was
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recorded; the co-articulation effects in phonemes adjacent to the test item can help in
identification of the target (Lynn and Brotman, 1981).
2.2.5.1.3 Phonemic Balance
Material having reasonable proportional representations of the sounds that occur
in everyday speech is said to be phonetically balanced (Egan, 1948). A PB list is one in
which all phonemes are represented in the list with the frequency of occurrence,
representative of everyday speech (Deves, 1963 and Mines et al, 1978). An alternative
way to obtain PB scores is to use word lists which contain the same proportion of
phonemes in each list i.e. iso-phonemic (Boothroyd, 1968). The score obtained for each
phoneme can then be weighted by its frequency of occurrence in everyday speech.
2.2.5.1.4 Visual Context
HIC even successful hearing aid users with moderate having losses, rely heavily
on visual information (Walden et. al., 1990). Although many of the consonantal
ambiguities, in auditory perception, can be resolved when visual clues are available, but a
comparison of audio and audiovisual presentation makes it possible to compare speech
processing using auditory cues only and also in combination with visual information.
2.2.5.1.5 Word Familiarity
Words which are encountered more frequently in real life, tends to be recognised
better in speech tests than words which are not. But still, even words used frequently,
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may not be familiar to young children or HIC. Familiarity of words has several effects on
the difficulty of speech tests.
• The score will be higher if more familiar words are there.
• The equivalence of the test will be affected if there are more familiar words in one
test than another.
• Within a list, range of familiarity of the words will affect the range of difficulty of
items within the list.
2.2.5.1.6 Response Set
There are two types of response set: open and close.
In Close set listeners are presented with a list having two to many alternatives
from which to choose. Test difficulty is greatest when response foils differ from the
stimulus by only one articulatory feature and especially when that feature is place of
articulation e.g. (fin, thin). The greater the number of alternative response set, the more
likely it is that any actual misperception will be available to the subject as a possible
response, however, responding becomes more difficult for the subject and score
decreases (Miller et al., 1951). Test with four to six response alternatives are most
common (House et al., 1965).
In Open set listeners repeats or writes words that are heard. An advantage
available to the tester is that he/she is able to find out exactly what the subject had heard.
But it is a disadvantage that scores will increase falsely, if some material is used again.
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Walker et al. (1982) reported the same disadvantage for closed response set tests, but the
extent of becoming familiar with the open set material is much greater.
2.2.5.1.7 Number of Items per List
The greater the number of equivalent lists available, the more flexibility with
which the test be applied to varying conditions in the experiments. But in real clinical
setting, a small test is preferred due to factors like shortage of time and fatigue of the
subjects.
2.2.5.1.8 Ability Tested
Examples of the task, with each type of ability being tested, are presented below.
Detection: speech is present or absent
Discrimination:
• Same / different (two stimuli)
• Pick the odd one out (three stimuli)
• ABX paradigm (third stimulus is same as the first or second stimuli)
The absence of discrimination ability makes the development of recognition
ability unlikely.
Recognition: Identify the stimulus words.
Comprehension: Answer the question or carry out some task.
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2.2.5.2 Attributes of Test Recording and Presentation Method
2.2.5.2.1 Response Method
1. For open response set tests, either the subject is asked to repeat, what they had
heard or to write their responses. But both these approaches can have additional errors,
e.g. verbal answers can be misheard by the tester and written misspelled answers can be
considered as misperceptions. So the best way is to get verbal as well as written response.
And the tester, ideally unaware of the answer, should make a decision after listening as
well as looking at the lips of subject in addition to the analysis of written responses.
2. Responding, by pointing or choosing the item from the list, in closed response set
tests is easy, both for the subject with no involvement of expressive language, as well as
for the tester requiring simple re-arrangement of items.
Another alternative to respond is to ask the subject to respond appropriately to the
stimulus. In a common object test by Plant and Moore (1992), subjects are asked to give
the asked objects and in Helen test (Ewerston, 1973), subjects are asked to answer the
questions.
2.2.5.2.2 Quantity Scored
Feeney (1990) has shown that increasing the number of items scored, increases
the test reliability and provides additional information about the errors made. There are
several ways of scoring i.e. phonemes scoring demands a higher concentration of the
tester and always lead to a high score than word scoring. A mono-syllabic word scoring is
easier than spondees or trochees scoring. Sentence scoring can be done in two ways, i.e.
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either scoring completes sentence as a single unit or by scoring each word of the sentence
separately. De Fillippo and Scott (1978) introduced the method of connected discourse
tracking in which the tester presents and represents words or phrases until the listener is
able to repeat them correctly. In this way the number of words per minute is scored rather
than the percentage of correct words.
2.2.5.2.3 Threshold Level
If one is interested in the maximum score or achievement scores under some
specific conditions, then the percentage of correct units is an appropriate measure, but if
one is interesting in finding out the speech threshold, then speech level, or signal to noise
ratio (at which 50% of responses are correct) are approximate measures.
2.2.5.2.4 Speech Level and SNR Adjustment
Speech levels are the maximum level attained by a VU metre during the course of
the items. Leq measurement refers to the equivalent continuous level, equal to the level of
a constant intensity sound, which has the same intensity as the average speech item
intensity. Although averaging of speech intensity can be restricted just to the vowel
portion of the word, but is normally performed over the entire duration of the word in a
sentence.
2.2.5.2.5 Adaptive Testing Levels
Range of intensity level can be recorded either by using a wide range of stresses
in sentence material or by recording the dialogue at different distances from the
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microphone. Although the most comfortable level is frequently used, which is believed to
be resulting in maximum percentage of correct responses from the subject, but it does not
result in maximum speech identification (Ullrich and Grimm, 1976; Beattie and Warren,
1982). By changing the level of each word in a test, the number of corrected items in a
test can be obtained to form different groups of words.
These adaptive levels, thus made, can be used to get performance ranging from a low
score to maximum score achievable by the subject. Adaptive procedures are most
efficient if all presentations are close to the level or SNR required, to achieve
performance at a certain criteria.
2.2.5.2.6 Speech and Noise Spectrum
Danhauer et. al. (1985) reported that speech signal’s spectrum and noise spectrum
are key attributes of any speech test, as only that speech is available to the subject which
is either above the subject's threshold and masking other competing signals in that
frequency region. Talker’s attributes and choice of the material also affect the spectrum
of speech. A noise like a babble of talkers are similar to long term average speech
spectrum, whereas traffic noise is more weighted towards low frequency and white noise
is weighted towards high frequencies. Speech tests results depend greatly on whether the
combination of signal and noise results in changing the high or low frequency energy.
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2.2.5.2.7 Noise Level Fluctuations
Plemp (1990) reported that while changing noise levels, when the noise level drops,
subjects will be able to get a greater amount of information, but subjects with greater
hearing losses are not liable to get advantage of such fluctuations.
2.2.5.2.8 Signal and Noise Source Location
Normally hearing listeners and to some extent H.I listeners generally find the test
easier if the signal and noise sources are separate, but most speech testing is performed
with noise and speech coming from the same loudspeaker, which rarely occurs in real life
situations. Danhauer and Johnson (1991) also reported the importance of distance of
signal and noise from the listener during speech testing. If this distance decreases, the
ratio of direct sound intensity to reverberant sound intensity increases, thus the easiness
of test also increases, unless this ratio is either much greater than or much less than 0 dB.
2.2.5.2.9 Live Versus Recorded Voice
The characteristics of the talker like voice level, manner, clarity, etc. are going to
influence the test results greatly if live voice is used either to maintain interest of the
listener or to provide visual cues, (House et al., 1965; Penrod, 1979; Hood and Poole,
1980) resulting in decreased test reliability. Thus, the use of recorded versions of speech
tests, are preferred. In addition, the recorded material can be edited to ensure uniformity
of acoustic characteristics and to suit the adaptive needs of small children.
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2.2.5.3 Dependent Attributes of Speech Test
Following attributes are the results of all above mentioned attributes, which can
be chosen independently.
2.2.5.3.1 Reliability
Theoretically, it refers to the degree to which repeated application of the same
speech test, under identical conditions, will result in identical scores. In practice, by
repeating the same test, the subject is not surely in the condition as before and if other test
is used, difference in difficulty levels of the test will surely affect the measurement of the
reliability of the test.
One way to find the reliability is to find standard deviation of repeated scores of
an individual and then to derive confidence limits for a single score. This way is useful
for assessing the effects of some training or sensory assistance on a single subject.
Another way is to measure the correlation between scores of some subjects on two
presentations of a test. The resultant correlation coefficient is representation of the ability
of a test to make distinctions among subjects.
2.2.5.3.2 List Equivalence
The lists of a speech test are said to be equivalent if any list would result the same
score when tested under the same conditions. For this purpose, items among different
lists need to be distributed in such a way that each list has same word familiarity and
phonemic balance. One way to get such lists is to use the same words in every list with
changed order, but learning of stimuli is evident, thus suitable only for determining
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speech recognition threshold rather than maximum attainable intelligibility. Edgerton et
al. (1981) reported the suitability of repetition of stimuli for nonsense syllables having
less potential for learning.
2.2.5.3.3 Difficulty Range Within Tests
For list equivalence, the difficulty range within list also needs to be equivalent.
Moreover the list with varied item difficulty is liable to provide a more reliable score as
compared to list with items of more uniform difficulty.
2.2.5.3.4 Performance Intensity Function
The graph of percentage correct either against the presentation level or against the
SNR is called the performance intensity function (PI) and the slope of the PI function (in
percentage per dB). It describes how much the test score is affected by the level or noise.
Tests with homogeneous difficulty items have steeper’s slopes. Similarly, tests in which
long term average spectrum of speech matches with that of noise or with the subject’s
threshold, the PI function have steeper slopes. Moreover the easy tests having high word
familiarity and limited response sets have steeper slopes.
2.2.5.3.5 Importance Function
It describes the relative contribution to the intelligibility of available signals in
each frequency region. French and Steinberg (1947) reported that speech intelligibility
can be predicted by articulation index (AI) method. The AI value increases more rapidly
with signal level when the signal spectrum matches the noise spectrum and percentage
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correct increases more rapidly with AI value for highly redundant (easy) material. It is
possible to calculate the importance function for individual subsets of speech tests, as
done by Duggirala et al. (1988). And the process can be extended up to the level of
individual sounds.
2.2.5.3.6 Validity
It refers to the degree with which the scores of a speech test can predict the future
performance in real life situations and reflect the difficulty experienced in actual
situations.
2.2.5.3.7 Population Factors Affecting Validity
Four factors, i.e. age at onset of hearing, current age, degree of hearing loss and
learning opportunities contribute to the special difficulties of devising valid speech
perception tests for HIC. When hearing loss is present at birth or acquired pre- lingually,
heterogeneity of subjects in terms of knowledge and skill required for speech perception
is reported because knowledge and skills are at considerable risk at that time. So it is very
important, while devising a speech test for this age group, to be clear about the aspect of
speech perception being tested and to design test accordingly. Similarly, consideration to
current age should be given while designing the test as it is of vital importance that the
tasks of the test are within cognitive capabilities of young subjects and are interested
enough to ensure their full participation. The increasing hearing loss is likely to
exaggerate the effects of age at onset. A pre-lingual profoundly deaf child is likely to
have serious long term effects on knowledge and speech skills. Boothroyd (1984) had
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reported that despite a score of zero on word recognition test, profoundly deaf had access
to phonologically significant information on the phonetic contrast test. Knowledge and
skills are also affected with the learning opportunities and these opportunities are of vital
importance in the years between onset of loss and speech perception testing. The
importance of learning opportunities increases with earlier age at onset and increasing
hearing loss. Gears and Moog (1990) have reported that speech perception skills and
other aspects of spoken language knowledge increase to the extent with which the
educational cum communication approaches have given it the importance, as their
primary goals.
2.2.5.3.8 Sensitivity
A test is said to be sensitive if the score changes with the change in measurement
conditions and the directions and extent of this change is reliable. Dillon (1982) shows
that test sensitivity can be maximised by choosing the test scores to be about 90% or
lower if the items vary, much in difficulty.
2.2.5.3.9 Efficiency
A test is said to be efficient if it is reliable and if it provides all necessary information
in a feasible time. There are three basic approaches to design such a test.
1. Figure of merit approach generates a single score to represent the speech
perception performance. The score is obtained by tests such as word recognition tests
for adults, age appropriate PBK lists, picture pointing tests, etc. It is quite
unreasonable to expect that these absolute scores will be equivalent, i.e. insensitive to
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differences of language knowledge and speech perception skills, but still these scores
help us in differentiating individuals.
2. The descriptive/analytic tests provide a detailed information about phonological
significant features such as voicing, place of articulation, etc. with an aim to
determine the need for and success of different sensory assistance provided, in the
form of a training. Other examples of such test, also providing score as an overall
figure of merit are Risberg’s diagnostic rhyme test (Risberg, 1976), Erber’s vowel
and consonant identification tests (Erber, 1972; Hack and Erber, 1982), a recent
Osberger’s change/ no change test of feature perception (Osberger et al.,1991) and the
Audiovisual Feature test of Tyler et al. (Tyler, Fryanf-Bertschy and Kelsay, 1991).
3. Both above approaches are time consuming as requiring many trials, for analytic
detail and establishing reliability. Thus, classification system is used by several test
developers e.g. Erber’s MTS test (Erber and Alencewicz, 1976), ANT test (Erber,
1980) and ESP test (Moog and Geers, 1990) etc.
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Part III
2.3 AURAL REHABILITATION
2.3.1 Rehabilitation Versus Habilitation
Habilitation refers to services, technological assistance and training for the
development of skill not present beforehand. Normally, efforts for reducing the effects of
disability present at birth, i.e. congenital deafness or pre-lingual onset of deafness, in case
of infants and children are the habitation targets for these individuals. Rehabilitation
therapy is basically meant for restoration of the any lost function or skill. For example, in
adults normally hearing loss is acquired later on due to some accident, ageing process,
etc. Although there are different types of habilitation and rehabilitation therapies
depending on the nature of the problem and its causes but to cover all those is not
required here. In the next section we are going to discuss aural rehabilitation, its nature,
services included, different styles and models and glimpses of AR practices in different
regions of the world.
2.3.2 Definition of Aural Rehabilitation
According to ASHA (2001) Audiologic/aural rehabilitation is an ecological,
interactive process that facilitates one's ability to minimise or prevent the limitations and
restrictions that auditory dysfunctions can impose on well-being and communication,
including interpersonal, psychosocial, educational, and vocational functioning. “Aural
rehabilitation is aimed at restoring or optimising a patient’s participation in activities that
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have been limited as a result of a hearing loss and also may be aimed at benefiting
communication partners who engage in activities that include people with hearing loss”
(Gagne, 2000, p.36). According to Ross M. Jara (1997) any device, procedure,
information, interaction, or therapy which lessens the communicative and psychosocial
consequences of a hearing loss. According to Tye Murray (2009), it is an intervention
aimed at minimising and alleviating the communication difficulties associated with
hearing loss. Montgomery and Houston (2000, p. 379) described AR as services that
"increase the probability that successful communication will occur between a hearing
impaired person and his or her verbal environment". According to Arthur Boothroyd
(2007, p.63) “Adult aural rehabilitation is defined holistically as the reduction of hearing-
loss-induced deficits of function, activity, participation, and quality of life through a
combination of sensory management, instruction, perceptual training, and counselling.”
AR is considered to be efficacious when it serves to reduce the disability experienced by
a patient (HIC), enhances psychosocial well-being and when the functional improvement
remains long after the rehabilitation was started. (Stephens, 1984 and Weinstein, 1996)
All these intervention combinations are also employed with deaf children. It is
clear from all above mentioned definitions that the main crux of (Re) Habilitation for
children and adults are same. But the differences present in child and adult AR can be
understood easily with the help of following figure.
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Figure 2: AR Service Plan by Tye Murray (2009)
Source: Tye Murray 2009, p.16
2.3.3 Aural Versus Audiologic Rehabilitation
Audiologic rehabilitation is a narrow breadth of services provided by audiologist
alone. Whereas aural rehabilitation service providers are multi-professional (Audiologist,
Speech Language Pathologist, Educator of the Deaf, communication partner, etc.)
covering a much broader range of services provided to hearing impaired individuals.
Services included in AR Plan are diagnosis and quantification of hearing loss, hearing
assistance technologies, auditory training communication strategies training,
informational/educational counselling, personal adjustment counselling,
psychological support, communication partner training, speech reading training, speech
language therapy, etc. These services can be provided to the target population at places
like any university/college, private practice clinic, hospital, community centre, otologist’s
office, public/private school, self-help groups, school for the deaf or even at home with
computer/ internet.
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2.3.4 Services Included in Aural Rehabilitation
Aural rehabilitation refers to services and procedures for facilitating adequate
receptive and expressive communication in individuals with hearing impairment.
Described by ASHA (1984), the services and procedures include, but are not limited to:
2.3.4.1 Identification and Evaluation of Sensory Capabilities
• Identification and evaluation of the extent of the impairment, including
assessment, monitoring and re-evaluation.
• Monitoring of other sensory capabilities (e.g., visual and tactile-kinesthetic).
• Evaluation, fitting and monitoring of auditory aids and monitoring of other
sensory aids (e.g., visual and vibrotactile) used by the H. I person in various
communicative environments (e.g. home, work and school) including group and
individual aids and supplementary devices as telephone amplifiers, alarm systems etc.
• Evaluation and monitoring of the acoustic characteristics of the communicative
environments of the hearing impaired person.
2.3.4.2 Interpretation of Results, Counselling and Referral
• Interpretation of audiologic findings to the client, his/her family, peers, teachers,
and significant others involved in communication with the hearing impaired person.
• Guidance and counselling of all significant persons about the educational,
psychosocial and communicative effects of hearing impairment.
• Guidance and counselling regarding available educational options and selection
for facilitation of communicative and cognitive development.
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• Individual and/or family counselling regarding: acceptance and understanding
of the hearing impairment; functioning within difficult listening situations; facilitation of
effective strategies and attitudes towards communication; modification of
communicative ummariz in keeping with those strategies and attitudes; and, promotion
of independent management of communication-related problems.
• Referral for additional services (e.g., medical, psychological, social, and
educational) if required.
2.3.4.3 Intervention for Communicative Difficulties
• Development and provision of an intervention programme specifically for
expressive and receptive communication.
• Provision of hearing and speech conservation programming.
• Coordination between the client, family and other agencies concerned with the
management of related communication disorders.
• Re-evaluation of the client’s progress and status.
• Evaluation and modification of the intervention Programme to fulfil individual
needs of the subject.
2.3.5 Aural Rehabilitation and Auditory Training
The research has supported the evidence that auditory training can be an effective
intervention for numerous auditory based disorders and problems arising either in early
childhood or at the decline of hearing in middle- and old age. Auditory learning is any
change in the listener’s ability to perform an auditory perceptual task contingent upon
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known and observed ummariz, whereas auditory training describes the nature of that
experience leading to the learning. Auditory learning includes enhancement of both top-
down cognitive processing and bottom-up sensory processing (Moore and Amitay, 2007).
They quoted the dramatic learning in just one and two presentations of a single
discrimination task which can be even longer lasting. Numerous variables like age of the
target group, extent of disability, the purpose of training, etc. will dictate the type of
training and the duration and frequency of training sessions. They concluded that
auditory training has the potential to revolutionise professional practices in audiology,
SLP, classroom teaching and other professions. However to have realistic expectations
from the sensory training is key to its successful application.
2.3.5.1 Fundamental Rules of Auditory Training
• Variation in training stimuli in order to suit the individual need is recommended
i.e. some individuals may benefit from more limited and from more varied training
stimuli.
• It is preferable to deliver several successive trials of the same type of stimulus
than to change the standard stimuli on each trial.
• One should be cautious towards variation in the training task because it may not
matter with adults but with children, nature of the task has substantial effects on gain in
learning and listening.
• Variation in training task is fruitful as it then becomes engaging and challenging
enough to produce strong learning.
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• Although the gain in auditory training depends on attention and arousal of subject
leading to its active engagement, but still passive exposure to tones has also resulted in
auditory learning.
Formal auditory training must meet certain criteria. It must be cost effective,
sufficiently engaging participants, easily accessible or home based, having immediate
feedback regarding responses, have active collaboration of different professionals and
should incorporate both bottom-up and top-down processes. Bottom-up approach is also
known as analytic approach which focuses on individual element of speech, e.g. training
in vowel identification, consonant discrimination, etc. It proceeds from large to fine
acoustic distinctions so called bottom-up. Top-down approach is also known as a
syntactic approach that employs meaningful sentences as training stimuli in the presence
of noise. The listener has to focus on comprehending the sentence without attending to
specific acoustic elements. This approach requires listeners to employ their knowledge of
language and context to fill in the acoustic/perceptual gaps in the message.
2.3.6 Aural Rehabilitation Strategies and Models
2.3.6.1 A Clinical Overview of Communication (Re) Habilitation for the
Hearing Impaired By Susan H. Brainerd
Susan had attempted to present the contemporary rehabilitation programmes for
different age groups separately. Variation in auditory reception and speech and language
development of the deaf population are expected to occur due to varying degree of
hearing loss, site of the lesion, age at onset of loss, etc. Thus she suggested that
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comprehensive, individualized programming to be facilitated by a reference to a flexible
model of normal communication. Derek’s Model (1982), comprehensive yet flexible
intervention program, suits this purpose as it includes both evaluation and development
of the language system, central processing abilities and methods for both transmitting and
receiving information. Sander’s model emphasized that as information can be transmitted
through various channels; speaking, writing, and singing, therefore the assessment and
intervention should also focus on receptive sensory capacities including auditory, visual,
tactile and kinesthetic.
Preschool HIC:
She quoted Bolton (1972) that 30% of H. I population have multiple disabilities,
thus habilitation programmes should involve multidisciplinary members to fulfil each
child’s educational, medical and social needs. Northcott (1977) mentioned the presence
of coordinator, nursery teacher, teacher for deaf, educational audiologist, psychologist,
speech language therapist, child development specialist, social worker, parent adviser,
medical specialists, occupational and physical therapist in any comprehensive team,
along with the discussion of their roles. Parents of preschool HIC are documented as a
valued member of the team, who can serve even as primary habilitator (Northcott, 1973).
Baker (1976) is quoted then for development of effective parent training (clinical or
home based programmes). Individual or group training is another available option. Some
contemporary programmes mentioned by her are Portage projects of Shearer and Shearer
(1976), READ project by Baker and Heifetz (1976) and home based curriculum guides
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by Alpiner et al. (1977), Clark (1977) and Northcott (1977). Acoupedic approach by
Pollack (1970) was the base of all curriculum guides. It involves early fitting and
continuous use of amplification and structural auditory development steps covering
specific training in awareness, discrimination, identification and comprehension areas, in
addition to distance hearing skill development.
For regular monitoring of progress through auditory (unisensory) approach,
several scales of assessment are quoted by Susan e.g. Northcott’s Auditory Objective
Scale, Northern and Down’s deafness management quotient etc. Adequate speech and
language development will be demonstrated by the children progressing satisfactorily
through auditory approach. For evaluation of language skills, Uzgiris and Hunt’s (1975)
pre-verbal language scales, Bloom and Lahey’s (1978) form by content analysis and
Ling’s (1976) evaluative programme for speech skills acquisitions are quoted. She further
added the importance of non-auditory instructional procedures, including visual, tactile
and/or kinaesthetic cues commonly referred as total communication, for those preschool
HIC who are not progressing satisfactorily through unisensory auditory approach.
School Aged HIC
It is of prime importance that school going HIC are provided with approximate
educational placement. Various suummarized educational services focusing on the
individual needs of HIC were provided at that specific time period. For example Ross
(1976a) recommended provision of aural /oral and total communication classes to HIC.
Both Ross(1976a) and Leslie (1976) recommended provision of the alternative
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programmes like regular class placement with or without supportive services, regular
class placement with additional instructional services, part-time or full time special class
attendance, enrollment in special school, home based programmes, instruction in
hospitals, residential or total care settings, etc. with an aim to move towards full
mainstreaming as quickly as possible, because regular classroom assimilation is the goal
of optimal communication (re)habilitation programmes for HIC. Several authors were
quoted who discussed the criteria of full mainstreaming of HIC, like Ross’ criteria,
systems O.N.E, etc. Again a multidisciplinary approach to comprehensive (re)habilitation
programming is recommended here. It was mentioned for preschool HIC that intervention
should emphasise on acquisition of basic listening and language skills, but for school
aged HIC, formal speech training is also recommended. She quoted McLean’s (1976)
articulation development strategies based on training through nonsense as well as
meaningful speech practices. She also quoted Ling (1976) who recommended the
teaching of sequenced speech patterns through several drills of syllables until they are
produced precisely and rapidly in several contexts and carried over to meaningful
communication situation. Ling proposed a seven stage model for speech development.
After increasing the vocalization capacities, supra-segmental aspects of speech are
practised. Vowels and diphthongs are practised in stage three. Next three stages are
meant for consonants. In the last stage consonant blends are summarized. Again,
multisensory instruction focusing on the development of all areas, outlined in the model
of normal communication in addition to speech development, is recommended due to
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varying auditory capacities of HIC, especially for those that don’t show progress with
auditory only stimulation.
Young Deaf Adults
Susan documented the several authors’ conclusions that although deaf young
adults had normal intellectual potentials, but they are reported as having low academic
achievements, delayed emotional development and vocational immaturity. Thus,
comprehensive habilitation programmes of these youngs are only those that cover
personal as well as social skill development, thus focusing on training in skills related to
both daily living and employment. Evaluation of H. I’s work personality and capabilities,
work adjustment for a specific period in stimulating work environment, skill training, job
placement and follow-up assistance are recommended vocational preparatory services for
these young H. I persons. For the purpose of assessing, directing, feedback and
counselling, each person’s preferred communication method and use of several
alternatives like speaking, writing, finger spelling, signing and use of interpreter’s help,
are recommended. In order to do a comprehensive communication evaluation of young
deaf adults, Susan quoted several options like screening battery developed by Johnson
(1976), CID everyday sentence and NTID communication skills profile, California
achievement test and standardized test and modification suggestion by Gochnour (1973).
For the purpose of intervention at the onset of therapy, formal speech reading
instructions are suggested rather than the use of auditory approach. Contemporary
researchers of that time stressed the training that covers familiarity with employed
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language, knowledge of message topic and visually contrasting speech movements, visual
acuity and ability to focus accurately, visual awareness and memory, flexibility and
practice in reduced levels of redundancy, etc. Further, she added the teaching of any
language through second language acquisition strategies, as in most of the cases sign
language is their first language.
Hearing Impaired Adults
Susan stressed that hearing impairment is not an isolated sensory deficit as with
age, changes in auditory, visual, tactile, kinaesthetic, olfactory and gustatory system are
likely to occur. This widespread engagement of sensory loss suggests a comprehensive
sensory retraining programme. She quoted Hardick (1976) to outline the characteristics of
successful rehabilitation programme for adventitiously hearing impaired adults that
includes client centred philosophy, group therapy techniques, involvement of important
others, consumer oriented information, information about available services etc. She
added that intervention programmes should follow a certain sequence i.e. providing
information about hearing loss, aid and services and agencies, orientation speech reading,
experimental use of aid before purchasing the aid, training for listening improvement and
lastly counselling regarding attitude and behaviours.
2.3.6.2 Audiological Rehabilitation: Management Model by D.P.
Goldstein and S.G. D. G. Stephen (1981)
The model is claimed as broad and general yet independent of any philosophy. It
incorporates instrumental and non-instrumental components and involves interaction of
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various procedures of rehabilitation. The suummarized view of model is depicted with
the help of computer flow chart showing different actions from macro to micro detail.
The outline of the model shows three levels of details. Each column shows the same
process in different detail. In first one, the whole aural cum audiological rehabilitation
process is divided into the segments of evaluation and remediation.
Figure 3: Audiological Rehabilitation Management Model 1
Source: Goldstein & Stephen (1981), Audiology 20, p. 434
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Evaluation
The evaluation covers the communication assessment of individual and all others
associated or related conditions mentioned in the second column. In the third column,
evaluation has the elements of detailed case history and audiometric evaluation focusing
on the communication difficulties of the individual. Other important elements mentioned
are assessment covering visual system, speech reading and manual communication and
psychological, sociological, vocational and educational variables in addition to assessing
the effects of any previous rehabilitation. But the most important element mentioned in
the section is assessment of language performance covering vocabulary, syntax and
phonology simultaneously.
Remediation
The lower half of the model addresses the duplicative and interactive remediation
segment of rehabilitation. Data gathered in the evaluation are analysed to make decisions
about the goals of the rehabilitation plan. The author has thrown light on detail of four
attitude types ranging from strong positive attitude towards aid and rehabilitation plans to
total rejection of them. After mentioning amplification and assistive devices, the author
gave importance to deriving goals that match with philosophy, lifestyle and capabilities
of the individual. The concept of coordination of all complex services (educational,
medical, vocational, social, etc.) for adequacy of rehabilitation is applaudable. The last
but most important goal of remediation is reported as to focus on communication training
of the individual. For this purpose, it is necessary to provide appropriate, relevant
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knowledge and counselling about aid, speech acoustics, make modifications if required
and skill building training to enhance effective communication.
2.3.6.3 Review of Different Curriculum Developed for Auditory
Habilitation of Deaf Children by Jane Freutel.
Before the mid-1980’s, traditional hearing aid technology made it possible that
auditory signals are available to HIC thus they were trained to use whatever residual
hearing they had. Their success was mainly dependent on features like early
identification and amplification, parent education and availability of support from
professionals. By 1984, cochlear implants and digital hearing aids were available that
made it possible to have expectations, even for profoundly deaf children, that they can
develop near-normal verbal language and speech skills. It is important to note that ability
to detect auditory signals is just a beginning of the habilitation process. Several curricula
have been developed to guide the professionals for developing auditory skills in HIC. But
not a single curriculum is complete guide thus adaptations and enhancements are
recommended to fit to the needs of the HIC. The four well known curricula that offer
sample lessons, material and skill checklists are discussed:
1. Doreen Pollack (1984) describes these levels of auditory functioning at the base
of any AR plan.
• Detection
• Discrimination
• Identification
• Comprehension
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2. Auditory skill instructional planning system (ASIPS) is formal curricula to assess,
develop goals and teach auditory skills. It also has four areas of auditory learning.
• Discrimination
• Memory sequencing
• Auditory feedback
• Figure ground
3. Developmental approach to successful listening (DASL) is organised around
these three skill areas.
• Sound awareness
• Phonetic listening
• Auditory comprehension
4. Speech Perception Integrated Curriculum Evaluation (SPICE) has three skill areas
as target (1996).
• Supra-segmental perception
• Vowel and consonant perception
• Connected speech
Professionals can use any of these curricula to have information about a child’s
current functioning level, to develop appropriate goals and plan strategies to meet these
goals, keeping in mind that the ultimate goal is to develop a listening attitude. Thus, all
rehabilitation team members should find ways to develop auditory skills in all situations
and verbal language and speech must be seen as part and parcel of auditory skill building
programmes.
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2.3.6.4 Bally’s Aural Rehabilitation Model (1999)
The model is claimed to be a source of demonstrating how cultural competence
can be infused into the AR process, in addition to illustrating how the diagnosis and
rehabilitative aspects of audiologic management can be merged.
Figure 4: Bally's Model
Source: EDHI conference, Jones R., & Bally S,. 2006, ppt slide no 73
Biological factors refer to the malfunction of the auditory system. Spiritual factors
refer to the wish of people for availability of support at the time of need. Cognitive
Macro-System Identifiers:
•Science/Technology
•The major influences on
economics, social accessibility,
quality of life issues
•Social security
•Medicare/Medicaid
•Welfare (welfare reform)
•Federal laws (i.e., ADA)
Meso-System Identifiers:
•Availability of services and
practitioners in the community
•Family support and support
groups
•Educational support for
hearing impaired children
•Parent support groups for
hearing impaired children
Micro-System Identifiers:
•Starting point for rehabilitation
processes
•Hearing disability is identified
using conventional
assessment techniques and devices (i.e. pure tone, SRT, SD,
etc.)
•Hearing aid evaluations are
conducted
•Speech reading assessments are
conducted
•Hearing handicap inventories and scales help identify:
•Personal or individual
resilience factors
•Concerns regarding loss of
hearing
•Effects on interpersonal
communication
•Other interpersonal effects (i.e.,
self esteem, etc.)
Cognition Spiritual Behaviors
Biological
Psychological Factors Personal Factors
Micro-Systems
Meso-
Systems Macro-Systems
Affective
Bally’s Model
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factors refer to the perception and knowledge about hearing loss and its effects.
Behavioural factors are the particular actions taken by the individual for management of
hearing problem. As the name suggests, affective factors are the emotional reactions of
H.I. All these factors make the micro-system of the model related to diagnostic elements
of the rehabilitation.
Scott Bally highlighted the following as micro-system identifiers.
• Preliminary diagnosis via case history, medical exam.
• Identification of hearing loss.
• Determination of hearing aid candidacy.
• Introducing the plan of rehabilitation.
• Assessment of effects on hearing loss, personality and communication
skills.
The meso-system of the model focuses on rehabilitation outcomes, i.e. availability
of health care professionals and their services, family support and educational
interventions.
Macro system of the model focuses on identification of national based systems like
technology advances, social, medical, legal and welfare reforms that are likely to affect
the AR services. He proposed the adaptation in the macro system identifiers over the
course of time for fulfilling the rehabilitation needs of the individuals. The contextual
system refers to how the personal and psychological factors interact at various levels of
the model.
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2.3.6.5 Aural Rehabilitation Directions Based on Massaro’s Model of
Information Processing. (Jay Lubinsky, 1986)
Lubinsky quoted Dempsey (1983) that procedure or models that do not define
specific processes do not lead easily to therapeutic goals and these have limited clinical
usefulness. Therefore Lubinsky stressed on using the model of information processing to
dictate the structural and functional aspects of AR programmes. From all other models of
information processing, Lubinsky preferred the Massaro’s model (1975) of information
processing due to its comprehensive detail of specific processes involved and their
bottom-up and top-down aspects. Diagrammatic representation of Massaro’s model is as
follows:
Figure 5: A model of Information Processing by Massaro
Lubinsky, J. (1986). Choosing aural rehabilitative directions: Suggestions from a model of information
processing. Journal of Academy of Rehabilitative Audiology JL, p. 28
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Intervention
In addition to focusing on the interaction of language, memory and attention,
specific therapy goals should be derived from results of assessment procedures. If
diagnosis indicates lack of world experience and knowledge, the first goal of therapy
would be to cover this area. He suggested that the extension of the model can indicate a
hierarchy of skills and needs to be preferred so that any clinician may choose initial and
subsequent rehabilitation goals.
He argued that logical reasoning leads to an order of importance in language
comprehension thus can dictate the order of priorities for intervention. As the information
contained in a message reflects the experiences and knowledge retained in long term
memory in addition to general world experience as a prime determinant of cognitive
ability, therefore he suggested it as the first target area of rehabilitation. Next he gave
importance to the semantic aspects of language, as vocabulary items are
multidimensional aspects of language and one of the weakest areas of H. I persons.
Afterwards the clinicians should cover the syntax and phonology areas. Last but not the
least, the therapist/Clinicians need to give subjects, every opportunity for sensory
processing, including appropriate amplification, corrected vision, and environmental
modification and they should choose the most appropriate sense modality for language
input. Throughout this prescribed hierarchy, the goals of the therapy should begin at the
highest level at which H. I person is deficient.
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2.3.6.6 Conversational Approach to Aural Rehabilitation by O.T.
Kenworthy (2002)
Initially rehabilitation of having impaired person was focused on improving
audibility, equalise loudness and improve word recognition because at that time, hearing
healthcare professionals consider hearing loss as an input problem. Then comes the stage
of auditory and visual speech recognition to restore effective communication which again
considers hearing impairment as input problem. Recently, many professionals have
addressed the problem in a broader context because of the interactive nature of
communication. They consider hearing impairment as both an input and output problem.
Therefore, people with an impairment need to develop strategies as both listener and
speaker for communication effectiveness. Similarly, several models of service delivery
emphasised conversational management. For example, Tye Murray (1998) had proposed
conversational repair strategies. Montgomery and Houston (2000) have proposed the
WATCH procedure which incorporates listening and conversational strategies to be
employed by people with hearing impairment. Schow (2001) has proposed the core/care
model which is consistent with the WHO definition of impairment, disability and
handicap. Schow’s detail goes beyond the contemporary services focusing personal
adjustment, assertive communication and conversational repair. Detail of the
CORE/CARE model is delineated in a separate section below. The important element of
conversationally based intervention targeting the successful communication of hearing
impaired persons is as follows.
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Assessment
AR profile is a conceptual three dimensional profiling system acting as a tool for
assessment and rehabilitation plans. The profiling notion is based on the concepts of
intra-linguistic profiling introduced by Miller (1981) and refined by Fey (1986). With the
help of the profile, it is possible to address all the domains and subdomains while taking
observations, case history, etc. in order to get a clear picture of primary communication
needs and strengths of the hearing impaired person. Thus the assessment summary
prepared with the help of this profile serves both as diagnostic report and basic AR plan.
Intervention
Kaplan, Bally and Garretson (1985) identify three conversational styles; passive,
aggressive and assertive, and listening and speaking behaviours unique to each of these
styles. Most of the professionals recommended the subjects to become assertive listener.
Thus the intervention approaches help to modify the listening and speaking behaviours of
H. I persons to reflect an assertive conversational style.
1. Acknowledgement Script
This technique has the elements of instructional strategies described by Tye
Murray, (1998) and WATCH procedure by Montgomery and Houston (2000)and is based
on the notion that persons, who acknowledge their disability are more likeable, sincere
and reliable as compared to those who don’t acknowledge. The acknowledgement script
contains a list of strategies that might be used by their partners in order to facilitate
understanding. Development of different scripts for one-to-one interaction, group
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conversation, specific individuals and specific situations versus quiet environment, etc.,
are likely to be made during ongoing AR. Active involvement, preferences and comfort
level and sense of ownership of H. I persons are key features of this script in reducing
withdrawal behaviours and increasing self-confidence of the subjects.
2. Conversational Repair
Breakdowns by speakers during communication are likely to occur, but H. I
persons are ill prepared to repair this disrupted communication. Therefore conversational
repair strategies are suggested both for children and adult subjects. These strategies
include a request for repetition, natural query, request for rephrasing, conversational
devices like “okay” Uh-huh”, request for confirmation or specification of conversational
elements and specific constituent repetition. There are four phases of using
conversational repair strategies. In the first observational phase, the subjects are provided
with an opportunity to observe the use of repair strategies by different persons. In the
second phase of familiarisation, subjects are informed about different strategies normally
used, their characteristics, their advantages and disadvantages. They are introduced to the
basic principles of conversational repair e.g. use of requests for clarification improves
understanding. Some requests are specific and some are not specific or non-contingent.
Contingent request for clarification are more likely to sustain interaction for longer
period.
In the third phase of discrete-trial phase, the subjects are asked either to observe
or to participate in the conversation with a professional or someone else. Opportunities
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that demand repair are introduced and conversant uses different strategies. After each
trial, strategies observed or directly used are reviewed and discussed to decide which
other strategies may have been appropriate. After the demonstration of the use of the full
array of specific strategies, the last implementation phase begins, which is similar to the
third stage except that artificial conversational barriers like noise are removed and natural
conversations are continued for 15 minutes. Afterwards self-evaluation is done in an
open-ended discussion and taking brief notes initially after one-to-one interaction and
later on after group interaction. Overall effectiveness of AR in based on post therapy
changes in the aural rehabilitation profile, measured across six artificial behavioural
domains, including sensory/perceptual, cognitive, linguistic, social, affective and
conversational.
2.3.6.7 CORE/CARE Model for Audiologic Rehabilitation by Ronald L.
Schow (2001)
AR involves both audiologic diagnosis and audiologic rehabilitation. This model, drawn
from WHO model, has attempted to provide professionals an efficient process for
standardised AR.
Rehabilitation is divided into AR assessment and AR management. The core
concerns of AR assessment and AR management are derived from the anchor points,
provided by WHO concepts of activity and participation and also includes personal and
environmental factors. Each assessment and management has four fundamental areas
summarised with anonyms CORE and CARE.
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Figure 6: CORE and CARE Model of Aural Rehabilitation
source: A standardized AR battery for dispensers is proposed, The Hearing Journal. 54(8):10-20, August
2001.
The detail of the flow chart provided in figure 6 shows that CORE assessment
areas include communication impairment and activity limitation, Overall participation
variables, Related personal factors and Environmental factors. Communication findings
are drawn from diagnostic audiometry and self-report. Overall participation variables are
drawn from social, emotional, educational, vocational and related personal factors,
including client’s attitude and presence of other disabilities. Environmental factors are the
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consideration of general context involving places and partners with whom the subject is
liable to communicate.
CCCCCCCCARE management areas include counselling, Audibility, Remediation for
communication activity and Environmental coordination and improvement in
participation. Counselling is the part and parcel of the whole process, starting from the
time of the fitting of aid till the end. It will not only be a source of information but will
also help the subject to set goals of treatment.
Audibility management focuses on amplification devices; fitting and functioning
of aid and hearing instrument orientation (HIO-BASICS). HIO-BASICS are the
Standardised Protocol derived, to be followed through the rehabilitation process. It covers
Hearing expectations, Instrument operation, Occlusion effects (echo), Batteries, Acoustic
feedback, System trouble shooting, Insertion and Removal, Cleaning and Maintenance,
Service of aid.
Remediation for communication activities covers five important communication concepts
summarised with the acronym CLEAR. (Control the situation, Lip-read, Expectations
that are realistic, Assertiveness and Repair Strategies).
Environmental and participation issue covers partners and places. The six
suggestions for partners of hearing impaired are summarised in acronym of SPEECH.
(Spotlight face and keep it visible, Pause slightly between sentences, Emphasise and be
patient, Ease the listening, Control the circumstances and listening conditions in the
environment, Have a plan while anticipating difficult listening situations).
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2.3.7 Glimpses of Aural Rehabilitation in Different Countries
2.3.7.1 NEW ZEALAND
In 1996, Jerram J.C and Purdy S.C conducted the first extensive survey to report
the hearing aid use and benefit and the accessibility of hearing association services. The
reported results of the survey indicated the limited knowledge and usage of local
rehabilitation services due to obstacles of physical access and financial and time
constraints. Hearing aid benefits were reported to be moderate at that time and not related
to variables of age and usage of aid. Adult hearing aid users wanted assistance with
hearing aid management and assistive listening devices. After seven years, a survey of
parents of high need (HN) and very high need (VHN) deaf students in mainstream
schools, was conducted by Mckee and Smith (2003). The following picture of AR in New
Zealand was revealed. A total of 1005 deaf and H.I students from primary to secondary
schools were classified as HN or VHN students out of which 82% were reported to be
mainstreamed by Stockwell (2000). Thus an estimate of 824 HN and VHN deaf students
in mainstream school was made by the author. 125 parents returned the questionnaire
thus making a response rate of 31%. 69.7% HIC were being deaf at birth. 54% were
having profound deafness and 40% were severely deaf. 20% of HIC had cochlear
implant. Out of the 124 mainstreamed students, twenty had attended a deaf unit/resource
class, and twelve had previously attended a school for the deaf. Out of all these
mainstreamed profound and severely deaf children, 67.2% were able to communicate
comfortably by oral mode of communication. 18.4% used both oral and manual modes of
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communication and only 14.4% were using signs only. Parental opinion about the
quantity and quality of AR services revealed that the majority of them were either
satisfied or very satisfied with the services provided to them.
The majority of these children were reported as availing services of teacher’s aide
and itinerant teacher i.e. 91% and 86%. And 78% were receiving services of an adviser
for deaf children. 44% reported to have access to the speech therapist. The services of
interpreters and auditory verbal therapist were available to only 3% of these children and
less than a quarter had access to a deaf resource person.
An important item of the questionnaire was “what were your main reasons for
deciding to mainstream your child?” Analysis of the responses showed the following
seven main reasons for choosing a mainstream placement. 52 parents reported it to be
proximity/ ease of transportation to the school. 37 parents considered these schools, a
source of socialisation in the normal world, twenty-nine parents had no other available
alternative and twenty-three considered that the mainstream schools had a better
academic level. 23 parents considered mainstream schools as a source of exposure to
spoken language and twenty-one parents found these schools very helpful. Whereas,
fourteen parents reported their dissatisfaction from deaf school as a reason for selecting
main stream school. They reported that special schools were not offering what they
demanded and due to the prevailing sign language environment, low quality of education
and/or support.
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2.3.7.2 USA
A survey to report about which aural rehabilitation service is provided and how
often and in which format it is provided, was conducted by Susan and Lori in 2002. Eight
AR services other than hearing aid fitting and orientation discussed in the literature
were:-
1. Information on assistive listening devices(ALD’s),
2. Auditory training,
3. Communication strategy training,
4. Coping strategy training,
5. Frequent communication partner training,
6. Informational/Educational counselling,
7. Psychosocial adjustment counselling,
8. Speech reading training.
Data obtained from 110 out of 300 (37%) highlighted the three most frequently
provided services, i.e. information on ALD’s, communication strategy training and
information/education counselling. After these, the order of most frequently provided
services was coping strategies training, psychosocial adjustment counselling, frequent
communication partner training, auditory training and speech reading. The format of
service delivery was informal as using handouts. The majority of them were provided on
an individual basis, but nearly half of the respondents indicated a lack of time as a barrier
to more service delivery. From eight AR components, the auditory training and speech
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reading training were least practised due to the formal nature and time demands of the
provision of these services.
In 2003, a survey was organised by Melody Harrison et al. to identify trends in
the age of identification and intervention of infants and young children with hearing loss
for expanded implementation of newborn hearing screening. Out of 657 parents receiving
the mail, the responses of 151 parents of HIC born between 1996 and 2000, belonging to
forty-one states, were analysed and compared with the age of identification and
intervention before wide spread implementation of newborn hearing screening. Findings
indicated that newborn hearing screening had lowered the age of identification and
intervention. It was also reported that when the hearing was screened at birth, infants with
more severe degrees of hearing loss tend to be identified and receive intervention within
the 2000 timelines proposed by the Joint Committee on Infant Hearing. By June 2000,
approximately 1000 hospitals reported screening at least 90% of the babies. The
prevalence of infants diagnosed with permanent hearing loss was approximately 20/1000.
The median age of identification and enrollment in early intervention was 3 months and
the median age of hearing aid fitting was 7.5 months. Identification occurred earlier for
infants from well-baby nurseries and for infants with severe to profound hearing loss.
After discussing the clinical practices of the audiologist in Illinois state and trends
in the age of identification and intervention for infants in the USA, a review of audiology
practices in school setup can help us to estimate the impact of these AR services in the
lives of hearing impaired there. The 2006 legislature directed the Washington State
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institute for public policy, to arrange a meeting of stakeholders in order to examine the
strengths and weaknesses of educational services available to HIC. A total of 573
individuals, including parents, students, teachers, interpreters, administrators and deaf,
hard of hearing and deaf blind adults were consulted. The data revealed that 90% HIC
attend local public schools, but these students account for only 0.1% of the total student
population. Most of these HIC students spend part of the school day in regular classroom
and part of the day receiving standardised one-to-one instruction or in a special education
classroom. Federally funded infant and toddler early intervention programme (ITEIP) is
responsible to provide early identification and evaluation of disabilities in addition to
determining eligibility for early intervention services. Country based Family Resource
coordinators (FRCs) are hired by ITEIPS to provide intervention services that includes
communication training for parents and children, support services for children with
cochlear implants, hearing aid evaluation and dispensing of other services. Under federal
law, educators determine the nature of the services required for special students in the
IEP planning process, and encourages inclusion in mainstream classrooms. Federal policy
guidance directs school districts to provide a range of educational placement options,
access to instruction in whichever mode of communication chosen by children and their
parents and services to address these students unique language and communication
barrier. Following weaknesses in educational and support services were pointed out by
stakeholders:
• Lack of a coordinated system
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• Limited professional services and expertise
• Widespread use of unqualified educational interpreters
• Isolation of HIC in mainstream schools
• Inconsistent provisions of information
• Lack of transition programmes and a disconnect between day-to-day
practice
The strategies suggested by stakeholders for improvement in educational services
for deaf students were:
• Creation of authority for coordinating services and their quality control.
• Development of regional programmes.
• Developments of standards for teachers and interpreters.
• Strengthened early identification.
• Expansion of technology based support resources.
In order to have a more comprehensive and in depth knowledge about the status
of specific AR services provided, 2000 survey of AR by Dallin Millington is reported
here. The results of the survey of ASHA certified audiologist revealed a decade (1990-
2000) trend in aural rehabilitation practices with a 9% increase in audiologists describing
their major responsibilities as both diagnostic and rehabilitative. There was a notable
increase (double) in areas related to cochlear implant therapy, tinnitus management and
outcomes measurement of devices and rehabilitation trainings, and a modest increase in
dispensing hearing aid and assistive devices, as well as auditory training practices. Very
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minor changes in the practice of hearing instrument orientation (HIO) were seen and
counselling remained as the most prominent activity of the practitioner (92%). Practice of
specific speech reading and group HIO training gained an overall decline in AR practices.
In conclusion new rehabilitation approaches were emerging and the profession was
showing expansion in AR practices.
2.3.7.3 CHINA
Aungst and Battle (2007) discussed the communication disorders in China. The
visit of China’s children's hospital, a school for the deaf and college of special education,
well equipped audiology programmes and China Rehabilitation Research Centre by
several ASHA members revealed that universal newborn hearing screening programme
was established in 1996. The Ministry of Public Health China (2002) indicated that
approximately 30,000 children were born with hearing loss each year and only 2% had
access to hearing aids. In 1986, the Ministry of Education, China declared nine years of
basic education, compulsory for the children with disabilities. Out of estimated 3 million
deaf children in China, only 33,000 were enrolled in the government run special need
schools located in urban areas. Several reasons like misperception of families of deaf,
lack of trained professionals near residence, lack of resources to afford room and board
(even in tuition free urban schools) lead to delay or even non-provision of education and
rehabilitation services to the deaf. There were fewer than 400 specially trained teachers of
deaf in 664 schools. Most of them were in urban schools with some training and learning
about the job. As a result, 54,000 school aged deaf children living in rural areas had no
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access to education. Many of the children in Xian deaf mute school had hearing aids or
implants and were prepared for a career in art. There were no computers or other
electronic devices for students.
Audiology is a relatively new profession in China, with 400 audiologists in the
country _ about one for every 300,000 people. Same was the case of profession of speech
language pathology having fewer than 200 SLPs. Thus physicians, nurses, psychologists
having additional training provide the services. New schools and hospitals were being
built with up to date equipment etc with an aim to have an additional 5,000 – 7,000
special educations by 2015. The hospitals and schools need 130,000 SLPs and audiologist
to provide services, train new professionals and provide professional development for
existing personnel.
2.3.7.4 VIETNAM
Final Evaluation report of inclusive education for hearing impaired and deaf
children in Vietnam by Charles Reilly and Nguyen Cong Khanh, submitted to US
Agency for International development grant holder Pearl S. Buck International on July
2004, is presented here to get insight of educational provisions for deaf in Vietnam. The
main objectives of this pioneering effort were:-
• Early identification of hearing impairment through audiological screening.
• Provision of hearing aid and referral to education services.
• Training of teachers and specialists.
• Collocation of Vietnamese signs and training in how to use the sign language.
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According to the Vietnamese government and UNICEF, more than one million
children have physical or mental disabilities. Children with hearing loss are among the
most neglected of disabled children, due to their difficulty in using speech. Despite their
normal cognitive ability, many people consider them as un-educable.
In 199, the government launched a campaign to promote inclusive education (a
strategy of full integration of HIC in regular classrooms). US AID (1997) launched a
“Children with disabilities” initiative to support special needs of these children, so grant
was awarded to Pearl S. Buck foundation (PSBI) and other foreign NGOs. An inclusive
education program for HIC was started in six provinces of Vietnam with the help of PSBI
and its government partner National Institute for educational services (NIES). The
following accomplishments were made by the pilot projects of inclusive education from
1999 – 2003.
• Screening of over 800,000 youth, leading to audiological testing of over 5000
children.
• Enrollment of more than 550 HIC per year.
• Distribution of more than 1,000 hearing aids along with training in the use of aid
helped in recognising the value of aid by parents, and educators.
• Initiation of regular audiological testing services at provincial resource centres to
keep a record of audiological assessment and provide assistance to schools having HIC.
• Provision of support to families for schooling of their HIC.
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• Conduction of training courses for parents and educators to introduce visual and
engaging approaches for HIC.
• Course of Vietnamese sign languages was attended by deaf people.
• Training of provincial resource teachers in early intervention audiology, sign
language and teaching methods, to help with conversion of special schools to provisional
resource centres.
Four key aspects described below were looked at, with the help of evaluation
programme, to see whether inclusive education programme had laid a foundation of
solid gains in child learning or not.
• Communication level with HIC.
• Teacher expertise to modify the instructions and activities to suit the child’s need.
• Parental and educators’ expectation from HIC.
• Social relationship of HIC in schools.
Data was collected by two evaluators (from Vietnam and United States) during a
structured interview of 112 stakeholders selected from twelve schools, two resource
centres, four district education offices and four provincial education offices, during the 20
day period of field visit in their provinces. Results indicated many similar gains as
reported earlier, but still a lot of problems described next were also identified.
The most serious problem was area of communication with HIC, which was
particularly lagging behind for severely and profoundly deaf children, comprising 60% of
the programme’s participants, due to the reason that both teachers and children lacked
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knowledge of common language. Finger spelling was the most developed communication
tool which is not a substitute for full national language, thus students were missing
contents of instruction and lagging behind in the classrooms. Few short courses in sign
language were not enough to prepare teachers, who in turn will teach sign language to
deaf students. As the children must learn language before they can learn academically,
therefore school must become a place where children can learn language in the normal
manner through interaction with others, although at a much delayed age. Alternative
structural arrangements were another option to support the goals of inclusive education,
e.g. grouping of all deaf children in one classroom in one school, etc. Teachers were at
the centre of Vietnamese model, responsible for language developments, communication
skill building instruction assessment and guidance. But the teachers, in need of ongoing
support like good information and special education techniques, were too much busy and
thus teacher centred model was not working to get the desired outcomes. Therefore a new
model, affordable and culturally acceptable is necessary. This new model development
will require at least three full academic years to observe its goal, e.g. development of
IEP’s and monitoring of these plans at the same site, carrying over the instruction of HIC
in two separate groups (One group of preschool children with benefits of early
intervention, another group of school age children with benefits of early intervention) and
expansion of such models to other sites of Vietnam.
Following are the main points of the recommendation made for inclusive
education of hearing impaired and deaf children in Vietnam.
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• Conduction of strategic planning study to determine the type of capacity of
schooling arrangement for HIC divided in two groups mentioned earlier.
• Translate a body of important research and policy paper from several nations.
Selection of topic for translation to be done by the foreign adviser on child development,
applied linguistics and deaf education.
• To extend the scope of screening, diagnosis and assessment.
• To focus more on individual rather than collective needs of these children and
developments of the individualised family support programme (IFSP), for monitoring of
programmes of each child in critical areas of language development and communication
skills.
• To create a model educational plan in one site to discover and to document “best
practices” in instruction and support for children with hearing loss.
• Tool developments in country’s main language.
• Early intervention.
• Increasing public awareness and a sense of responsibility for educating disabled.
• Put every HIC in an educational setting where they can learn the primary language
easier for them or chosen by them.
• Developments of full corps of highly skilled teachers for provision of inclusive
education to HIC.
• Increased opportunities for social day at school e.g. meetings in schools.
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2.3.7.5 TURKEY
A study to determine the age of suspicion, identification, amplification and
intervention in children with hearing loss in Turkey, was conducted by Esra Ozcebe et al.
(2005). The data was obtained from parents of 199 children referred to their centre
between the years 1999 and 2004. Parents reported that hearing loss was suspected and
identified at a mean age of 12.5 and 19.4 months respectively. The average ages of
amplification and intervention were 26.5 and 33.0 months respectively. When these
findings were compared with the data of 156 children followed at the centre between
1991 and 1994 years, it was evident that there was significant improvement in the age of
suspicion, identification and intervention, but these were still far below the ages
suggested by the Joint Committee on Infant Hearing.
2.3.7.6 INDIA
A survey by Nachiketa Rout and Udhay Singh (2010) was conducted to estimate
the age of suspicion, identification and intervention revealed the prevalent condition of
available provisions of AR of H. I individuals in India. Although the universal screening
programme is yet to begin in India, but the average age of suspected hearing loss in
children is 1.5 years. At two years of age first consultation with doctors is arranged.
Among those who consulted a doctor, 21% parents are directed not to worry and they go
for some home remedies, and only 33.4% parents are referred for audiological assessment
of their child. 53% parents suspecting the problem consulted a second doctor and 50% of
those were recommended to initiate AR programmes. On average at 9.3 years of age,
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parents meet with the audiologist and 95% parents don’t consider it as any delay. He
reported the following factors being responsible for delay in provision of AR services.
• Child rearing practices in India.
• Ignorance about importance of hearing and critical age for speech and language
development.
• Lack of AR services.
In India there is a combined cadre of audiologist and speech therapist responsible
to provide AR services to H. I individuals. There are 1567 registered ASLP in India that
can cover only 30% of Indian population. Therefore, 34% H. I are detected after 5 years
of age. 93.3% of H. I belonged to income group of less than 6500 per month and only
5.7% of HIC are able to receive an AR before 3 years of age (critical period). Out of the
70% children diagnosed as having speech and hearing problem only 33.4% avail SLT’s
services and 89% children were indicated with bilateral severe to profound degree of
sensory neural hearing loss. Clinical observations of HIC revealed only 6% were having a
verbal mode of communication mostly restricted to word level only. None of profound
HIC was found to have verbal expression of sentence level.
Most of the clinics in India have a noise level of 55 dB and above. As the first
consultation in India is always with ENT specialist and most of them recommended to
wait rather than initiation of AR programme thus awareness programmes for ENT is
likely to have for reaching effects on not delaying the AR in India.
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2.3.7.7 THAILAND
Krishna Lertsukprasert and Benjamas Prathanee (2005) reported that in Thailand,
the most common mode of communication for deaf children was total communication
which focuses on sign language, but the method limits the ability to communicate with
other hearing people as it requires an interpreter. Due to these problems, a preschool
programme for deaf children was set up in 1993 at the speech and hearing clinic of Khon
Kaen University. 31 profoundly deaf children aged 1 to 6 years who entered the
preschool oral communication training programme, were provided the training in a group
of 4-6 children with a teacher and assistant under supervision of an audiologist and SLP.
The training of 3 hours per week covers the targets of auditory training, speech and
language development, parental guidance and counselling etc. At the end of each session,
performance and problems were noticed to guide the next session. Listening and speaking
performance was evaluated 6 month interval. The authors found that it took 9 months to
train the child to produce meaningful words and approximately 21 months to acquire
simple conversation. The mean age of enrollment was 2 years and 10 months. There was
no relationship between age of enrollment and the listening and speaking ability. There
was a weak correlation between age at the first starting auditory training and number of
days required to detect the first sound. But there was neither correlation between the
degree of hearing loss and the numbers of days required to detect the first sound, nor the
correlation between the age at the first starting training and number of days to produce a
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first meaningful word. The results would have been different if the limiting factors were
not present.
2.3.7.8 IRAN
Naeimah Daneshmandan et al. (2008), while reporting the AR condition in
Tehran commented that key to intervention with deaf children is to establish a functional
communication system for them. They suggested the intervention programme that is
multidisciplinary, technologically sound and in correspondence with the culture of the
society. A prospective longitudinal study was undertaken to check the feasibility of oral
communication development in the severe to profound HIC. Oral communication skills,
that rely on what the deaf child can hear, was assessed by means of speech intelligibility.
The sample of the pilot project was having mean hearing threshold of 78.8 and the
mean age at beginning of auditory habilitation was 17 months. The average of their
speech intelligibility score was near 70% at age 6 which is considered as poor and only
two subjects were able to communicate by spoken language. Songs were designed on the
basis of oral enhancement techniques and workshops were arranged for parents, therapist
and educators to introduce these songs along with group playing and group singing.
Meanwhile the children were attending regular preschool for the whole year (6 – 7 years
of age). The test material of speech intelligibility test consisted of ten questions having
words compounded of difficult consonant like fricative, back stop sounds, etc. The
questions were read by each child and recorded in order to be presented to a listener at
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normal comfortable level. Each child’s tape was given to ten students of the Shahid
Beheshty University to listen to questions and write down their only one word answer.
Results indicated that all of the severe groups were over 90% and had oral
communication, whereas only two profound children, using total communication,
achieved the score of 62% and 48% and had semi intelligible speech. They further
indicated that in Tehran, in the past two years, there were only two inclusive schools and
they demanded more special education services based on oral communication teaching
methods. The result of these public intervention services was that seven severe and
profound children could be enrolled in regular school and one profound one took part in
inclusive schools. They agreed with Olusanya that pilot studies are necessary in each
country to guide health care delivery programmes and thus recommended more such pilot
studies to be done. Another noteworthy recommendation cum findings of the study was
that integrated nationwide public school will save further investment in special schools
for the deaf.
2.3.7.9 PAKISTAN
A study regarding parental awareness about auditory performance of their hearing
impaired children who were receiving regular speech therapy and to assess their
participation level in auditory skill development of their children with hearing loss was
conducted by Anjum Bano Kazimi (2008). The data obtained from the parental
questionnaire was verified by personally observing the auditory skill level of children e.g.
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sound awareness, attention, localisation and discrimination of sounds both in noise and in
a quiet environment.
There were marked difference in auditory skills of the HIC in noisy and quiet
environment. And only 50% children were able to localised environmental sounds only if
it is loud enough. Discrimination skills were the poorest among all other skills, as 90%
HIC were not able to discriminate two loud environmental sounds. Although 70%, 3–9
years old children with severe to profound loss were using analogue body worn (50%)
and B.T.E. (50%) hearing aid consistently, but mode of communication of the majority of
these children was sign language and total communication. The data showing most of
parents communicating with sign language and 90% of them had never used any activity
or game for improvement in auditory skill development, shows the lack of awareness of
parents about the importance of development of auditory skills for their children. Author
stressed on individually referenced performance measure to be developed in order to
monitor the effectiveness of medical, audiological instructional and communication
interventions. Despite all the efforts to adopt the norm referenced standardised
achievement tests, development of technically sound assessment tools that are integrated
component of the instructional process, were recommended by the author. Provision of an
enriched auditory environment, individual based auditory verbal therapy, training of
teachers and parents regarding the auditory skill development, multidimensional team
assessment and monitoring of the child’s progress were further recommendations of the
author.
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Another study in the same year, aiming at evaluation of auditory perception skill
development in cochlear implanted deaf children was conducted by Zakirullah et al.
(2008). Pakistan cochlear implant programme was started in 2000 and they reported 150
subjects had undergone cochlear implant at Karachi, Lahore and Peshawar during period
2001- 2007, whereas over 200,000 patients had received cochlear implant worldwide. 21
children were selected on the basis of following criteria, i.e. under 12 years of age,
having implant for a period of at least one year, high motivations and expectations of
family and the child having access to education and rehabilitation follow-ups but without
any additional illness or syndrome for assessment of auditory perception skills. EARS
test, comprised up of seven tests and two questionnaires was used as tool of assessing
speech perception skills of these children pre-operatively and at intervals of one week,
one month, three months, six months and twelve months after switch on.
Results indicated that all three age wise groups made noticeable progress in
vocalisation pattern, alertness, attendance and understanding of sound stimuli. They
stressed the fact that rehabilitation programme is as important as the surgery itself. Result
suggested that cochlear implant children develop speech recognition soon after
implantation and these skills develop over a long period of time, highlighting the need of
continual of therapy for maximising listening and learning of these children. The study
quoted EARS test result by other authors that older children started at a higher
performance level, but their young peers catch up within 24 months of device use. They
suggested that a team approach is mandatory for a successful outcome and these patients
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need to be continuously rehabilitated and monitored. A significant effect of age at
implementation was also demonstrated by the study.
2.3.7.10 Hearing Healthcare for Children in Developing Countries:
A global perspective by Sara, A. and Thomas, B.S. (2013)
McPherson (2008) describes a country as developing which has low average
annual income and economy and is based on agriculture or primary resources. According
to World Bank if a country’s average annual income is less than $ 10,065 per person, it is
developing. There are more than 100 such countries, including India, Saudi Arabia, etc.
In developed countries audiology covers proper screening, diagnostic assessments,
hearing aid fitting and rehabilitation. But in developing nations, audiologists are limited
and many children with hearing loss go undetected. Some countries such as Africa and
India have a combination of speech language pathology and audiology programmes,
which still don’t have the standardisation of course contents. Technicians, nurses and
other health care providers provide the audiology services as any licence to practice is not
a requirement. Permanent hearing impairment is due to genetic or environmental factors,
but the majority of it is preventable. Otitis media is the most common preventable causes
of hearing loss in developing countries, but it normally goes unchecked and treated thus
leading to lifelong impairment. Sensory neural genetic hearing losses associated with
drugs, noise, poor pregnancy case, infections like measles, meningitis, etc., are
preventable if given due importance by hearing health care providers. But socio –
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economic and health care condition in developing countries do not help in the prevention
of congenital hearing loss.
UNHS programmes have been established as a standard of care for infants in
many developed countries, but the main issue of funding for UNHS programmes in
developing countries along with lack of professionals, superstitions beliefs,
consanguineous relationships, lack of awareness and education of parents etc. are present
as obstacles to start such programmes in developing countries.
WHO (1995) has urged all countries to prevent and control hearing loss by
supporting early detection, but developing countries are slower in addressing the
importance of early identification, A combination of both community based hearing
screening programmes and hospital programmes are proposed, as majority of newborn
are born at home or private maternity homes. Targeted hearing screening of infants born
with risk factors like low birth weight, family history of hearing loss, etc., for hearing
loss is another starting point option for these developing countries.
WHO has estimated that 32 million hearing aids per year are required by
developing countries, but supplied with only these quarters of a million per year. After
the issue of poor screening and diagnostic facilities, the cost of hearing aid is the main
obstacle. Hearing aid manufactures markup haring aid to almost ten times its
manufacturing cost. Even if these aids, are provided free of cost they are resold due to
extreme poverty and parent being unaware or uneducated as in Guatemala. And if not
sold, due to higher repair and maintenance cost of the aid, they are still not used. Despite
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ever increasing population, there is an urgent need to provide HIC with rehabilitation
options. Educating parent’s on childhood hearing loss is necessary for the success of any
screening and rehabilitation programme in developing countries.
Olusanya et. al. (2007) quoted in “Progress towards early detection services for
infants with the hearing loss in developing countries” that the health care system in many
developing countries were weak, with poor government funding, due to the presence of
high mortality diseases like T.B, HIV, AIDS, Malaria etc. Systematic development and
expansion of intervention programme are recommended with the help of pilot studies in
these nations, to demonstrate the feasibility of any planned programme and to identify the
potential incoming challenges. A questionnaire based survey was conducted in at least
two countries selected from sub regions, based on UNICEF/world bank classification in
order to get information about their models of infants hearing screening, the financing
mechanism, parental and health professional attitudes and achievements of these
programmes. Responses were obtained from two paediatricians, nine otolaryngologists
and five audiologists belonging to sixteen out of eighteen sample developing countries.
No response from Pakistan or Kenya was obtained at the time of reporting by the author.
Nepal and Bangladesh were excluded from the list as they reported that no infant hearing
screening programme had commenced there. The data obtained revealed that the earliest
started programme was in India in 1986. The second oldest screening programme in
Brazil (1988) had 237 screening sites, thus the largest one in any developing country.
Oman was the first developing country with a national program on new born hearing
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screening, after prior pilot studies in various regions of the country. Chile had just
implemented a national initiative to screen almost half of the newborn with known risk
factor for hearing loss. Iran had conducted pilot studies in twenty-eight of its thirty
provinces.
The majority of the screening programmes were reported to be hospital based
except in Nigeria, South Africa, Taiwan and Hong Kong (limited extent in China, Jordan,
Oman)having community based programmes. In most of the countries, existing health
care professionals were responsible for screening projects except in Nigeria, where non-
specialists are given training to conduct the screening. Nurses are involved in screening,
but diagnostic testing is handled by an audiologist and otolaryngologists. In majority,
parental attitude towards infant hearing screening was found to be positive, with most
positive in Nigeria and uncertain in India. Similarly, health professional attitude was
mostly rated as positive.
The recommended target of 95% screening coverage was achieved in Nigeria,
South Africa, Hong Kong, Singapore and Mexico. The referral rate at discharge was
lowest in Oman i.e. 1.2% and the highest in one Hong Kong pilot study i.e. 44.7%. The
referral rate in Saudi Arab, Oman and Brazil fell within the recommended target of 4% or
less. The rate of “returned for follow-up” showed the effectiveness of tracking system.
The recommended target of 95% was only attained in Saudi Arabia and Oman and was
lowest in South Africa 39.7%. In the absence of UNHS, age of diagnosis varies from
about 18 to 86 months.
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It was concluded from the report that hearing screening is feasible as a public
health initiative in developing countries. Although nationwide implementation is
hampered by several factors like low public awareness, resources constraints and lack of
government and donor supports, but the most successful programme often had small
beginning and gradually scaling up of their extent. Brazil, Oman and Chile had
progressed from rudimentary pilot projects to the multi-city programmes, and many of
pilot projects had sustained without public funding.
Tucci and Debara (2010) reviewed the literature on the prevalence and causes of
hearing impairment and the global impacts of hearing impairment in developing nations,
in order to focus on the need and priorities for prevention and effective treatment
programmes. Lack of wide spread comprehensive immunisation programme and other
medical care and inadequate funds for intervention etc, were identified as responsible
factors of high prevalence of hearing loss in developing world. Once hearing loss is
identified, cost effective prevention and treatment opportunities can be generated by
International government and non-governmental Organisation.
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CHAPTER 3
METHODOLOGY
The main objective of the study was to develop and validate the model of aural
rehabilitation. For this purpose, a survey was designed to assess the present system’s
strengths and weakness as in the view of stakeholders involved in the process of
rehabilitation and to incorporate their suggestions in the model. The “Logic Model
Development Guide” developed by W.K. Kellogg Foundation, (updated on Jan 2004)
was studied as a guide to understand all the components involved in the process of
development of the model. Contemporary aural rehabilitation models were assessed
against the five basic components of the model. The common elements of these models
and the stakeholder’s recommendations were incorporated in the model. For the purpose
of validation of the model, an experimental study was designed. A standardised norm
referenced tool for speech perception testing (developed in Urdu language) was used
during the pre and posttest scoring of the experiment. Reliability and validity of the test
were established through a pilot study.
For the purpose of delineating the method and procedure of the study, it is organised into
four sections. All these four sections are the mirror images of the four objectives of the
study.
SECTION A deals with the need assessment surveys of special education centres in
Punjab.
SECTION B deals with the development of the Model of Aural Rehabilitation.
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SECTION C deals with the development of the tool of experimentation.
SECTION D deals with the validation of the model of aural rehabilitation via
experimentation.
3.1 SECTION A
For the purpose of development of model of aural rehabilitation, it was justified to
critically appraise the rehabilitation services already available to the hearing impaired
individuals in Punjab. Thus, a survey was designed to analyse the effectiveness of the
current provisions in special education centres/ schools/ institutions.
3.1.1 POPULATION
All (161) the special education schools/centres/colleges dealing with hearing
impaired children, under the Directorate of Special Education, Punjab was the population
for this section of the study.
3.1.2 SAMPLE
Sample was selected by using two stage cluster sampling. In first stage the
schools were selected and in second stage sample of teachers, parents of HIC,
audiologist, speech therapist and principal was taken.
Total thirty institutes were randomly selected as a cluster in following way:
1) Only 3 degree colleges were in Punjab, all were taken as a cluster sample.
2) From 161 Punjab government special education schools/centres catering HIC, twenty-
seven special education schools were selected. Detail is given in table 2.
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Table 2: Sampling Distribution of the Institutions
9 divisions of Punjab Higher secondary
/secondary school
Middle
schools
Centres having all
four disabilities
Bahawalpur Division 1 1 1
D.G khan Division 1 1 1
Faisalabad Division 1 1 1
Gujranwala Division 1 1 1
Lahore Division 1 1 1
Multan Division 1 1 1
Rawalpindi Division 1 1 1
Sahiwal Division 1 1 1
Sargodha Division 1 1 1
Total 9 9 9
In second stage of cluster sampling 20-30 parents of the HIC studying in these
institutions and 10-15 teachers were randomly selected. A speech therapist, audiologist
and the principal of each institution was also included in the sample. Detail is depicted in
table 3. A list of the selected schools, along with the name of the focal persons
responsible for delivery and collection of the questionnaires, is attached in Appendix F.
Table 3: Sample Size distribution
PARTICIPANTS NUMBERS
Parents of HIC in schools 30 × 20 = 600
Teachers of HIC in schools 10 × 20 + 10 × 2 = 220
SLTs of HIC in schools 1 × 30 = 30
Principals of HIC in schools 1 ×30 = 30
Audiologists in the schools 1 × 15 = 15
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3.1.3 INSTRUMENTATION
For survey, questionnaires were self developed to cover all the stakeholders
involved in the rehabilitation of HIC in school setup in Punjab. The open, closed and
Likert type items were formed depending on the nature of information required. Items of
the questionnaire were based on the following themes:
• Demographic information
• Information about communication status of HIC
• Information about listening skill development of HIC
• Information about available general as well as specific provisions/facilities for
aural rehabilitation of HIC
• Information about current professional practices for aural rehabilitation of HIC
• Perception of the stakeholders regarding strength and weakness in the current
system of habilitation of HIC
• Information about problems faced by the stakeholders and their recommendations.
The five questionnaires developed were as follows:
1. A Questionnaire for the parents of HIC studying in special education school.
2. A Questionnaire for the teacher of HIC teaching in special education schools.
3. A Questionnaire for the principal/ Administrators of special education school.
4. A Questionnaire for the speech therapists employed in special education school.
5. A Questionnaire for the audiologists working in special education centres.
A copy of all questionnaires can be found in Appendix A, B, C, D, and E respectively.
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Pilot testing was done in the National Special Education Centre for HIC
Islamabad, before mailing the questionnaires to thirty randomly selected special
education schools. Each questionnaire’s reliability via Cronback alpha was checked
separately and found to be at 0.8. The sample of pilot testing consisted of the ten parents
of HIC, ten teachers, three audiologists, three speech therapists and two principals /
administrators.
At least one focal person’s telephone number was obtained from thirty institutes
selected and a set/bundle of questionnaires containing one questionnaire each for
principal, speech language therapist and audiologist, ten questionnaires for teachers, 20
questionnaires for the parents of HIC students to be randomly selected by that focal
person were sent to him/her to coordinate the distribution of questionnaires in his/her
institute. All focal persons were contacted and guided again and again to get the best
responses from the targeted population. The filled questionnaires were received back by
the researcher and analysed thereafter.
3.1.4 DATA ANALYSIS
Separate analysis of each questionnaire was done mainly by calculating simple
percentages. Analysis was divided into segments like:
• Data related to demographic details
• Data related to available provisions to the professionals
• Data related to HIC’s speech and hearing development
• Data related to professionals’ methodology and practices
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• Data related to the recommendations of all stakeholders
NVivo 11 pro was used to code the obtained responses of the stakeholders through the
questionnaires. All obtained recommendations of parents, teachers, speech therapists,
audiologists and principals from the questionnaires having frequency of at least 5 were
considered as a valid recommendation to be incorporated into the model.
3.2 SECTION B
Theoretical development of the model of aural rehabilitation was done with the
help of “Logic Model Development Guide” developed by W.K. Kellogg foundation
updated on Jan 2004. It is considered to be a beneficial tool facilitating effective
programme planning, Implementation and evaluation. Basic programme components of
the basic logic models are:
1. Resources needed to operate the programme
2. Activities are processes, techniques, tools, events and actions of a planned
programme including products and services.
3. Outputs are the direct results of programme activities. They are described in terms
of scope of services and products delivered by the programme.
4. Outcomes are specific changes in attitude, behaviour, knowledge, skill level of
functioning expected to result from programme activities and are expressed at an
individual level.
5. Impacts are organisational community, and/or system level changes expected to
result from programme activities.
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Various aural rehabilitation models developed for children and adults were analysed via
NVivo 11 pro against these five basic components of logic models. All models were also
coded against the five major themes, which were the five basic components of the model.
Repeated or prominent features of these models, if applicable to the Pakistani
circumstances, were incorporated into the proposed structure of the model. The proposed
model was personally discussed with the senior officials of directorate, hospital and
higher education institution, to further obtain their comments about the strengths and
weaknesses of the model. All suggestions of these officials were incorporated to finalize
the model.
1. Analysis of Bally’s Model (1999) showed that there has been more stress on
resources and tools of the model. Both personal and environmental factors were
given due importance and assessment of HIC covers a broad range of speech,
language, diagnosis and identification of hearing loss, hearing aid candidacy and
evaluation of personal factors. Minor detail about targets / services to be delivered
along with the outcomes of the model and impact was provided.
2. Similarly Tye Murray (2009) had outlined the ecological, economic and
psychological resources required. The evaluation covered the hearing and speech
along with demographic, conversational fluency and extent of communication
handicap. According to her detail of the model, service to be delivered to HIC
included communications strategies, counselling, assertiveness training, speech
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perception training, etc. she had not thrown light on outcomes and impact
separately.
3. Management Model of Aural Rehabilitation by Goldstein (1981) was assessed
to be more general type outlining the assessment tools required to assess
communication status and other associated and related variables e.g. visual,
psychological, sociological, educational, vocational mobility, etc. Types of
services to be delivered by this model included instrumentation covering
amplification, alerting system, sensory aid and instructions, communication
training covering skill building, information, counselling and modification in
instrumentation in addition to acceptance and understanding of the problem and
having reasonable expectations. Outcomes of model were outlined as a change in
attitude and auditory skill level, having impact on vocation and education of HIC.
4. Aural rehabilitation model based on the model of information processing (1986)
highlighted specific details of how sound waves and acoustic signals are detected
by the brain (primary perception) and changed into neural codes or meaningful
perception units (secondary perception). Structural and functional components of
memories helped in transfer of memories. Perception processes involved, both
bottom-up i.e. detection and discrimination and top-down i.e. previous knowledge
of linguistic structure and contextual rules of phonology, syntax, semantics, etc
processes. According to the model, short term memory is generated by abstract
memory and it could hold seven chunks of information for 15 seconds. With
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practice and rehearsal, it could be increased. Level of services to be delivered may
be based on these specific details of information processing, thus thorough
assessment, amplification, environment modification involving all input
modalities, rich language exposure, training of bottom-up skills targeting highly
affected areas and remedial work were given importance in the model.
Assessment of isolated skills like detection, recognition, etc. and work on primary
and secondary recognition, vocabulary building, etc. were the core concepts of
this model. This model focused on designing therapy from assessment. The model
viewed auditory impaired clients as a unified population with needs that can be
described within a single connected framework.
5. Watch procedure delineated by Montgomery (1994) had just thrown light over
the goals/targets of the services to be delivered to the hearing impaired
population. The knowledge about hearing loss and health care, amplification,
training, regarding lip regarding, repair strategies situation control and
assertiveness and asking specific questions were required for rehabilitation of
these individuals.
6. CORE/CARE Model, drawn from WHO’s by Schow (2001) model had
described the tools necessary for assessment of individual. Assessment included
assessment of environmental factors like places and partners, assessment of
personal factors like attitude towards disability, assessment of overall
participation variables like social, emotional, educational, vocational and most
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importantly the assessment of communication status in different activities.
Rehabilitation services were psychosocial and informational counselling, attention
towards possible audibility options including fitting of aids and aid orientation,
remediating communication activity focusing on both personal training like repair
strategies, assertiveness, etc. and environmental training like lip reading,
development of reasonable expectation rather than escape and control over
situations.
7. From all the models reviewed above the model of AR based on Model of
Communication by Sander (1976) proved to be comprehensive enough covering
all the five components of logic model development in detail. According to the
model, the parents were the primary habilitative agents. Tools of evaluation like
pre-verbal language scales, deafness management quotient, optimal functioning of
aids, auditory objective scales, goals of education and criteria for mainstreaming,
multidisciplinary team and evaluation of classroom acoustic were required.
Action/ planned activities required were acoupedic approach having structural
auditory development steps, auditory evaluation and monitoring of auditory
progress, appropriate educational placement after language and speech skills,
evaluation and development of non-auditory instructional procedure (total
communication) for children not progressing by oral approach, etc. Detail on the
type and level of targeted services included Ling seven stage model for speech
development, evaluation of each specific area of the model by conversation and
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by applying screening battery for assessing discrimination skills, speech reading,
level of manual communication, reading, comprehension, speech intelligibility
and vocabulary building. The rehabilitative auditory approach may be client
centred involving significant others, including group therapy techniques,
amplification and counselling.
3.2.1 DEVELOPMENT OF THE PROPOSED MODEL OF AURAL
REHABILITATION:
After the analysis of the above mentioned models of aural rehabilitation and the
need assessment surveys of the special educational school/centres/ colleges of Punjab, all
the necessary and common elements of these models and important findings of the survey
as well as the recommendations of the stakeholders were decided to be the part of the
proposed model of aural rehabilitation for profound HIC in Punjab. As the model was
broad, covering all major details as well as specific enough to highlight the specialised
services to be delivered thus, named as COMPREHENSIVE AURAL
REHABILITATION MODEL (CAR). The diagrammatic representation showing the
main gist of the proposed model was prepared. The summary of the model along with a
10 item questionnaire (Appendix G), having probing questions was personally discussed
and delivered to the multi-professionals (considered as experts in their field) to comment
on it. The professionals from medical field, educational sector and directorate of special
education were contacted for critical appraisal of the model. The list of the persons along
with their designation and addresses is attached in Appendix H. Their personal views and
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comments were obtained during discussion and all their proposed oral and written
recommendations were incorporated to finalize the structure of the proposed model.
3.3 SECTION C
This section deals with the development and validation of the tool required for the
experimental validation of the model of Aural Rehabilitation (CAR). As any validated
standardised tool to check speech perception skills of hearing impaired children in
regional languages, was not available, so a speech perception test in Urdu language was
developed and named as URDU SPEECH PERCEPTION TEST (USPT) for HIC.
3.3.1 METHODOLOGY
After extensive review of related literature about the speech perception test
development, normal development of auditory skills in children and different tests
developed in regional languages, it was decided that the test will cover the four major
areas of auditory skills development i.e. detection, discrimination, identification and
comprehension. A questionnaire to check content validity of the proposed test was
prepared (Appendix I). The structural and content details of the speech perception test
was personally delivered and discussed with the following professionals:
1. Three audiologists
2. Three speech therapist
3. Three Urdu language experts.
The name, designation and the name of the institute of these professionals along
with their recommendations are attached in Appendix J.
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3.3.1.1 Detection:
Initially, both environmental and speech sounds (in isolation) were included in the
proposed structure of the test. The child was required to simply raise his/her hand if
he/she felt the presence of any sound (coming from behind the child).
The professionals recommended excluding the environmental sounds and to take only
speech sound stimuli as the test was meant to measure speech perception. Thus the clap
sound and door knocking were excluded from the main body of the test, but included as
an optional attention seeker or a distracter during testing.
Ten speech sounds, including three vowels and seven consonants covering both
high and low frequency areas were selected. Moreover, this selection was also based on
the phonemes that were found to be having the highest frequency of occurrence in
everyday speech. Frequency of occurrence of each Urdu phoneme is summarised in the
table 4 (shown in the fourth coming identification section of this test).
3.3.1.2 Discrimination
The task of discrimination was divided into two areas.
i. Gross Discrimination based on supra-segmental perception e.g.
• High versus low frequency phoneme
• Long versus short duration vowel
• One versus bi versus multisyllabic
words
• Phoneme versus words
• High contrasted words containing
- High/low contrasting vowels.
- High/low contrasting consonants.
• Two items having same words were included as distracters.
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The child was simply required to respond whether the two incoming sounds were same or
different.
ii. The fine discrimination segment was purely based on consonantal differences
present at initial, middle and final position of words with same vowels. Out of three
words, two were same and one was different at any position of presentation of the
words. The child was asked to tell, which one of the three words was different from
others by telling the first, second or third position of the targeted word e.g. bar, car,
bar. The answer was second word was different.
Three lists (ten items in each) were prepared containing mono and bi-syllabic words
having same stress and intonation, but differing only in consonants at initial, middle or
final position. Then ten items were randomly selected from the lists covering these
contrasts.
• Voiced versus unvoiced consonants
• Voiced versus voiced consonants
• Unvoiced versus unvoiced consonants
The seven paired items of one syllabic word and three paired items of bi and tri-
syllabic words were present in the list.
3.3.1.3 Identification
For the task of identification, a list of twenty-five phonetically balanced
words (12 mono-syllabic and thirteen bi-syllabic words) was prepared after following
these steps.
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• A list of 138 most common Urdu words taken from preschool Urdu
readers was prepared. Three points Likert scale questionnaire was developed to rate
familiarity of these words (Appendix K). The questionnaire was filled by fifteen native
Urdu language speakers belonging to different districts of Punjab. A list of the persons
and their district of domicile is attached as Appendix L. Words that were not considered
common by the speakers were omitted from the list except yoyo. A final list of 125 words
served as a pool for the selection of phonetically balance word list.
• For the purpose of development of the phonetic balance of Urdu language
initially, only 700 mono-syllabic words were extracted from speech sample of 1200
words, keeping in mind that most of the tests in English language have mono-syllabic
phonetically balanced words. But the analysis of 700 words showed that 80 % of these
words were functional words without specific meaning independently. The review of the
tests developed in different international, regional languages like Cantonese, Ilocano and
Talugu revealed that they have not preferred mono-syllabic words. So it was decided to
take the speech samples as a whole having combination of mono, bi, tri and multisyllabic
words.
• Initially in addition to spoken sample, a written sample of 700 words
(taken from the Urdu textbook of class 3) was also included in the analysis. The
phonemic analysis was close enough to phonetically balanced Urdu Corpus having 18.2
million words developed at the centre for the research in Urdu language processing
(CRULP). CRULP also used the written Urdu samples in their analysis, but this
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phonemic analysis was significantly different from the phonetic analysis of the spoken
samples. So it was decided to exclude the written sample analysis (phonemic) and only
the spoken Urdu speech samples (as it were uttered/spoken) were used. The table below
shows the summary of difference in Written and Spoken Urdu language samples.
Table 4: Comparison of Phonemic and Phonetic Analysis of Urdu Speech Samples
PHONEME/SOUNDS Frequency of Occurrence of
the Phoneme in Written
sample
Frequency of Occurrence of
the Phoneme in Spoken
sample
/t/ 44 4 ٹ
/d/ 16 0 ڻ
/g/ 49 21 ڱ
/f/ 9 21 ف
/v/ 29 17 و
/s/ 73 51 سصث
/z/ 15 24 ضزظ ن
/ẑ/ 45 15 ژى
/h/ 135 76 ه هح
/m/ 67 102 م
/ č / 24 15 چ
/l/ 56 88 ل
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As, a whole speech sample was taken and it was cumbersome and not convenient
for the researcher to do the vowel analysis in addition to consonant analysis at initial,
middle and final position separately. Therefore, the vowel analysis by Raza (2009) was
kept in mind and the most occurring eight vowels were given preference in final list
formation.
The detail of three samples of spoken Urdu language used in the analysis is as follows.
• Sample A: It was a combination of different scripts spoken by different age/sex
speakers at different occasions, recorded by the researcher and consisted of 670
words in total.
• Sample B was recorded by the teacher of the Playgroup of Silver Oaks School, when
children were freely communicating with each other and with the teacher. It
consisted of 680 words.
• Sample C of 800 words was the conversation between parents, teachers and children
at a parent teacher meeting in the same local school.
All speech samples were written by the researcher and the frequency of occurrence
of all Urdu consonants along with their aspirated phones were counted. Mean frequency
of occurrence of Urdu consonants from three speech samples was calculated. The
researcher noted the following trends during the phonetic analysis of the three samples
while comparing it with other phonemic analysis.
1. Language code switching, i.e. use of English words as it is, in Urdu language was
becoming very common, e.g. words like car, gate, cup, etc. were included in Urdu
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language. Thus the researcher also added such words in the word list for
identification.
2. The phoneme /h/ at middle and especially at final position tended to be omitted or
replaced by a vowel or diphthong by the speakers.
3. The phoneme /ẑ/ mostly tended to be substituted by a diphthong by Pakistani Urdu
speakers in everyday life.
4. The high frequency of the phonemes (/k/, /v/, /s/, /ẑ/ /h/, /m/, /n/, /j/, /r/, etc.) was
due to the excessive presence of the functional words in every day Urdu speech of
the people.
5. Frequency of /r/ was highest at the final position among three positions.
After deciding upon the mean frequency of occurrence of Urdu consonants along
with their aspirated phones, the final list of 25 words for the task of Identification was
generated. The words, from the pool of 125 words were chosen in such a way that the
phonetic occurrence of each phoneme of the selected word list was almost equal to the
calculated phonetic balance for twenty-five word list. And the vowels with highest
frequency of occurrence were given preference as indicated earlier.
3.3.1.4 Comprehension
The final task of the speech perception test was to check the comprehension of the
speech heard by the listener. Initially the common questions related to the child like
name, father’s name, age, number of siblings, favourite colours, etc. were included. Later
on, the recommendations of the speech therapist and audiologist working in National
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Special Education Centre Islamabad were incorporated. They recommended that the
comprehension task should also be like other three tasks, not requiring the vocal response
from the being tested. So the sentences carrying one, two, three and four information
carrying words (ICWs) were incorporated in the test, despite the researcher’s view that a
child reaching this level of comprehension was surely able to respond orally. It was done
because the researcher personally liked the idea of non-verbal responses from the child.
Final version of Urdu Speech Perception Test is attached as Appendix M. Summary of
the Urdu Speech Perception Test (USPT) attributes is as follows:
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Table 5: Attributes of Urdu Speech Perception Test
Content Detection Discrimination Identification Comprehension
Linguistics Sounds in
isolation
Supra-
segmental,
vowels in
mono,
bi and tri-
syllabic
words
Consonants
in mono
and
bi-syllabic
words
Mono and
bi-syllabic
words
Questions carrying
up to four
information
carrying words
Phonetic
Balance
No No No Yes No
Acoustics Vowels
And
consonants
Vowel versus
vowel, Vowel
versus word,
Mono versus
mono and bi-
syllabic words.
Tri versus tri
and bi-syllabic
words
differing only
in vowels.
Words
differing
only
in
consonants
at all
positions in
words
Words in
isolation
Speech with
natural intonation
Response
Set Closed 2-
choice
Closed 2-
choice
Closed 3-
choice
Closed +open
choice
Closed + open
choice
Method Yes/no
response
Same/
different
Response
Pick the
odd
one out
Point to
the picture
Choose from the
given objects and
follow command
Number of
of items per
list
10 10 10 12+13=25 5 Sentences
No of List 1 1 1 1 1
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3.3.2 DATA COLLECTION AND ANALYSIS
A pilot study was conducted for the purpose of establishing the reliability and
validity of USPT.
3.3.2.1 Selection of Children for Pilot Test
A local mainstream coeducation school and a special education school having the
targeted age group was randomly selected. 100 normally hearing children were randomly
selected for speech perception testing in such a way that approximately five boys and five
girls belonged to the age range of 4-14 years. Thirty HIC were randomly selected in such
a way that two profoundly impaired children and one severely profound child wearing
bilateral digital hearing aids belonged to each age group.
3.3.2.2 Administrator of Test
Two testers, (the researcher and a volunteer) separately for normally hearing
children as well as for HIC were decided to take the test of the selected students during
school hours. The volunteers were given an orientation to the purpose and procedure of
testing. Moreover, they were guided during testing and first ten tests taken by them were
monitored for proper evaluation and scoring by them. The written guidelines were also
provided to both volunteers (taking the test of normally hearing children and HIC) for the
purpose of reinforcement of the considerations to be kept in mind while taking tests. The
child being tested was trained to respond by pointing to the pictures of twenty-five
phonetically balanced words. Moreover, if the child’s age was less than or equal to nine
years, it was decided that for his/her convenience he/she may be asked separately to point
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to the pictures of twelve mono-syllabic words and then to the thirteen bi-syllabic word.
Both tasks’ of discrimination and identification task involved the test of auditory memory
also.
3.4 Section D
This section deals with the validation of the CAR model for HIC in Punjab. As
the canvas of the model covers a broad range of individuals providing services to HIC, It
was not feasible to apply the full spectrum of the model and then find its implications on
the lives of HIC because, it will surely be a task of years. Therefore, only the aural
rehabilitation plan specifically dealing with the development of speech perception skills
of profound HIC was decided to be validated via experimentation.
3.4.1 DESIGN OF THE EXPERIMENTAL RESEARCH
Gay (1996) wrote in his book of educational research that the true experimental
designs represent a very high degree of control and are always to be preferred. Therefore
the Pretest-posttest control group design was selected. The design involves at least two
groups, both of which are formed by random assignment: both groups are administered a
pretest of the dependent variable, one group receives a new treatment, and both groups
are post tested. Posttest scores are compared to determine the effectiveness of the
treatment.
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3.4.2 POPULATION
All profound HIC provided with bilateral digital or semi digital hearing aids
(approximately 70) studying in ten public special educational schools/centres of
Rawalpindi district were considered to be the population of the study.
3.4.3 SAMPLE AND SAMPLING PROCEDURE
3.4.3.1 Selection of a School
The contact numbers of the speech therapists or senior teachers, working in the
special schools of Rawalpindi district were obtained by using personal links. They were
contacted either telephonically or via visiting them to get the information about hearing
impaired children using bilateral B.T.E., digital hearing aid. A school, with the highest
number of children with profound deafness using bilateral hearing aids was selected as
the sample school of the study. The principal/ administrator was contacted to get the
permission of conducting the experiment. A copy of the application forwarded to the
principal is attached in Appendix P. He gave the permission after discussing the
objectives and procedure of the study with a condition that any HIC selected for training
must not miss any important academic activity.
3.4.3.2 Selection of the Children
The information about all HIC studying in the selected sample school using
bilateral hearing aids was gathered by personally visiting their classrooms and discussion
with their class teachers. A list of those children was prepared and the information about
their ages and degree of hearing loss was obtained, after the detailed scrutiny of the
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student’s files, kept in the record room of the school. Following considerations were kept
in mind while making a list of children eligible for experimentation:
1. Children using only digital/semi digital aids.
2. Children having a profound hearing loss in both ears.
3. Children belonging to the age group of 4-14 years.
The children with mild, moderate or severe degree of hearing loss, children
having an analogue type of aid or children older than 14 years were excluded. A list of
thirty children, fulfilling the required criteria was prepared.
3.4.4 RESEARCH INSTRUMENT
Standardised USPT validated in previous section was the tool of the experiment.
3.4.5 FORMATION OF CONTROL GROUP AND EXPERIMENTAL
GROUP
All children were pre-tested after orientation to all four areas of assessment of
speech perception skills (dependent variable of the study). Younger children were
provided training on how to respond yes/no and same/different with the help of
modelling by another therapist or older HIC students. Children with pretest scores were
then divided into two groups (12 HIC in each group) while keeping the following
considerations, in order to equate both groups:
• Equal number of boys and girls randomly assigned in both groups.
• Children were paired according to their age group, each assigned to one group
randomly.
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• Children were divided in two groups so as to equate the total pretest score of both
groups.
• A senior teacher was involved in the procedure while randomly assigning the children
to control and experimental groups.
3.4.6 PREPARATION FOR THE TREATMENT
All children’s contact numbers were noted and their parents were informed of the
reason of their selection for research. The parents were counselled about the purpose and
procedure of the auditory training (independent variable of the study) along with its
expected benefits. They were motivated, by the far reaching effects of auditory training
as explained by the researcher and they ensured the researcher to send their children
wearing a bilateral hearing aid regularly. For the purpose of training of 30-45 minutes per
day, experimental group children were divided into two age groups.
• Five to nine years old.
• Ten to fourteen years old.
A timetable, for providing auditory training to these two groups was prepared in
such a way that the children would come to the researcher in the period of drawing,
physical training or vocational subject. Such a mechanism was adopted to ensure that
these children might not miss any important academic activity, especially periods of
speech and language development. The result was that all children of control and
experimental group were attending the regular timetable of academics except the
training provided by the researcher. The relevant teacher was informed of the time of
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auditory training of HIC of the experimental group so that possible arrangements be
made for remedial class work of the child. Moreover the class teachers of the control
group students were requested to make it sure that the children must be using the hearing
aids daily.
3.4.7 METHODOLOGY OF EXPERIMENT:
Place of the experiment: The Speech therapy room of Sir Syed Academy.
Duration of the experiment: 6 weeks.
Material of the experiment: Sources of high/low frequency environmental sounds e.g.
drum beat, clap sound, flute, mobile phone, toy phone, landline phone ring, piano, toy
computer, whistle, bell, horn. Flash cards, white board and coloured white board markers,
puzzles, toys, picture dictionary, etc. are the few to be mentioned here.
Training areas of the experimental treatment: Children were provided training of
four-six weeks in the following areas of auditory abilities.
• Detection of any sound (first environmental then speech).
• Detection of vowels.
• Discrimination and identification of long tensed vowels in isolation.
• Discrimination and Identification of short, laxed vowels in isolation.
• Identification of vowels in bi and multisyllabic words.
• Identification of any vowel in many syllabic words.
• Detection of voiced consonants (nasals, lateral, retroflex, plosives, fricatives,
affricates).
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• Detection of voiceless consonants (plosives, affricates, glottal).
• Discrimination of voiced and voiceless consonants in isolation.
• Discrimination of voiced and voiceless consonants in mono-syllabic words.
• Discrimination of voiced consonant in bi and multisyllabic words.
• Identification of consonant in mono, bi and multisyllabic words.
• Identification and discrimination and comprehension of mono-syllabic words.
• Identification and discrimination and comprehension of bi and multisyllabic
words.
Practice in recognition of most common words in connected speech e.g. names,
daily living things, fruits, vegetables, colours, animals, birds, body parts, alphabets,
counting, etc. was not covered in the training. Due to the short time period, only words of
tests were bombarded for identification and discrimination.
3.4.8 COLLECTION AND ANALYSIS OF DATA
It follows the following sequence:
i. Pretest speech perception scores of both control and experimental group were obtained.
(Appendix Q)
ii. Mean and standard deviation of pretest scores of both groups were calculated.
iii. t-test was applied to check the significance of difference in mean pretest scores of both
groups.
iv. The decision was made to accept or reject the null hypothesis i.e. there is no significant
difference in mean pretest scores of HIC of control and experimental group.
138
v. After providing auditory training of six weeks duration to the experimental group, HIC
of both groups were re-tested. Posttest scores of both groups were tabulated. (Appendix
Q)
vi. Mean and standard deviation of posttest scores of both groups were calculated.
vii. Once again t-test was applied to check the significance of difference in mean posttest
scores of both groups.
viii. The decision was made to accept or reject the null hypothesis i.e. there is no significant
difference in mean posttest scores of HIC of control and experimental group.
ix. t-test was applied to check the significance of difference in mean pre and posttest
scores of the control group. The decision was made to accept or reject the null
hypothesis, i.e. there is no significant difference in mean pre and posttest scores of HIC
of control group.
x. t-test was applied to check the significance of difference in mean pre and posttest
scores of the experimental group. The decision was made to accept or reject the null
hypothesis i.e. there is no significant difference in mean pre and posttest scores of HIC of
the experimental group.
xi. Age wise comparison of these HIC was done at pre and posttest level to check whether
there is any significant difference in scores of 5-9 years and 10-14 years old HIC.
xii. Gender wise comparison of these HIC was done at pre and posttest level to check
whether there is any significant difference in scores of the boys and girls.
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CHAPTER 4
PRESENTATION AND ANALYSIS OF DATA
The chapter deals with the analysis and interpretation of the data and the chapter
was divided in four parts.
I. PART A deals with the data analysis related to the survey questionnaires.
II. PART B deals with the detail of all components of the proposed CAR model.
III. PART C deals with the data of establishing reliability and validity of Urdu
speech perception test.
IV. PART D deals with the data analysis of independent and dependent variables of
the experiment.
4.1 PART A
This section deals with the analysis of data related to survey questionnaires. The
response rate of 50% (448 out of 895) was achieved as a result of continuous reminders
and requests from the researcher. The response rate of each questionnaire is tabulated.
Table 6: The response Rate of Each Questionnaire
Questionnaires No. of questionnaires received
Principals’ questionnaires 14
Teachers’ questionnaires 107 (having details of 886 HIC)
Parents’ questionnaires 308
Audiologists’ questionnaires 7
SLTs’ questionnaires 12 (having details of 191 HIC)
Total 448
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The responses to all five questionnaires were analysed separately.
4.1.1 TEACHER’S QUESTIONNAIRE
Out of 300, 107 questionnaires were received back, containing details of 886 HIC
(475 boys and 411 girls). The results and analysis of the received data are tabulated and
interpreted below:
4.1.1.1: Demographic Data:
Table 7: The Age and Gender of the Teachers of HIC
Age Range of Teacher F % Gender F %
26-30
31-35
36-40
41-45
46-50
51-60
No response
40
17
12
3
12
6
17
37.3
15.8
11.2
2.8
11.2
5.6
15.8
Male
Female
18
89
16.8
83.1
Total 107 100.0 Total 107 100.0
The table shows, most of the teachers were freshly inducted by the government
i.e. 37.3% teacher belonged to age group of 26-30 years, 15.8% teachers belonged to age
range of 31-35, whereas 15.8% teachers did not enter their age. The female teachers
141
dominated the field of special education as 83.1% teachers were female and male
constituted only 16.8 % of the sample.
Table 8: Qualification and the Post Held by the Teachers
Name of Degree f % Post of Teachers f %
F.A
Bachelors
Master
M. Phil
11
14
76
6
10.2
13.0
71
5.6
Junior Teachers
Senior Teacher
No response
34
65
8
28.9
60.7
7.4
Total 107 100 Total 107 100
The above table shows, most of the teachers i.e. 71% were holding the Masters
degree and the majority of them i.e. 60% were employed in grade 17 as a senior teacher.
Only a small proportion of teachers were not properly qualified whereas a small
proportion did not enter their post title or nature of appointment.
142
Table 9: Experience and Professional Qualification of the Teachers
Experience in years f % Professional
Qualification
f %
1-4
5-8
9-12
13-16
17-20
21-24
More than 24
No response
36
30
14
8
5
2
6
6
33.6
28.0
13.0
7.4
4.6
1.8
5.6
5.6
B. Ed
Diploma for Deaf
M. Ed
M. Sc
Untrained
No response
16
23
38
18
1
11
14.9
21.4
35.5
16.8
0.9
10.2
100.0
Total 107 100 Total 107 100
As far as professional qualification was concerned, 35.5% teachers were having
M. Ed, 16.8% were having M. Sc, 14.9% were having B. Ed and 21.4% were having
teaching diploma for the deaf whereas 1.2% did not enter their professional qualification.
Untrained teachers were only 1% the total sample. But these professionally strong
teachers did not have much experience of teaching HIC i.e. 33.6% had 1-4 years of
experience and 28% had 5-8 years of experience of teaching HIC whereas 5.6% them did
not enter years of experience.
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4.1.1.2: Data Related to HIC
Teachers were asked to enter detail of the students of their classes. In total, detail
of 886 HIC was obtained from these teachers. Analysis of information about these HIC is
delineated below.
Table 10: Ages and Degree of Hearing Loss of HIC
Age of child f % Degree of Hearing Loss F %
4-6
7-9
10-12
13-15
16-18
19 and above
No response
63
73
139
182
107
40
282
7.1
8.2
15.6
20.5
12.0
4.5
31.8
Mild
Moderate
Moderately severe
Severe
Profound
Don’t Know
No response
4
38
30
107
384
31
292
0.45
4.28
3.38
12.07
43.34
3.49
32.95
Total 886 100 Total 886 100
Data about HIC was having A diversity of age because nearly all age ranges were
there. 20% children were belonging to 13-15 year age group, 15% were in 10-12 year age
group and 12% were in 16-18 year age group. Whereas 31.8% of children’s ages were
not mentioned by the teachers. As far as the degree of hearing loss was analysed, teachers
reported that most of the children i.e. 43% were having profound degree of hearing loss
and 12% were having A severe degree of hearing loss. A small proportion of teachers
144
mentioned that they don’t have the information about child’s hearing loss and 33%
teachers did not enter the detail of hearing loss.
Table 11: Provision and Type of Hearing Aid of HIC
Provided with Hearing Aid f % Hearing Aid Type f %
No
Yes
No response
693
175
18
78.2
19.7
2.0
Body worm
Behind the ear
Others
74
99
2
42.2
56.5
1.1
Total 886 100 Total 175 100
As the table shows, the majority of HIC i.e. 78% were not provided with the
hearing aid. Out of those provided with aid, 56% were having behind the ear hearing aid,
and 42% were having body worn aid. Two children in the sample were having the
cochlear implant.
Table 12: Usage and Comfortability of HIC with Hearing Aid
Using Aid Regularly or
not
f % Comfort with aid f %
No
Yes
91
84
52
48
No
Yes
98
77
56
44
Total 175 100 Total 175 100
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As the table shows, out of those children provided with a hearing aid, nearly half
of children i.e. 52% were using them on daily basis and 48% were using occasionally.
Similarly, 44% of the HIC provided with hearing aid were comfortable users of aid and
56% were still not comfortable with their aids, as reported by their teachers.
Table 13: Speech Therapy and Communication Level of HIC
Speech Therapy
sessions/week
f % Communication Level f %
1-2
3-4
5-6
No Session
No response
140
34
120
564
28
15.8
3.8
13.5
63.6
3.1
Sign Language
Sounds
Words
2-4 Words
More than four words
No response
290
56
189
62
35
254
32.7
6.3
21.3
6.9
3.9
28.6
Total 886 100 Total 886 100
Data regarding provision of speech therapy to HIC and their current
communication style and level revealed that majority of HIC i.e. 63% were not having
access to speech therapists, services. 15% HIC were having 1-2 sessions of speech
therapy per week and 13% HIC studying in special schools, were getting intensive
therapy sessions per week. 63.6% teachers did not bother to enter the information
146
regarding speech therapy sessions of the children. As far as children’s speech and
language development was concerned, information about 28% HIC was not provided by
the teachers, 32% children were using only sign language for communication and 21%
were having the word level of speech for communication as reported by teachers.
4.1.1.3: Teaching Methodology and Teacher’s, Recommendations:
Data analysis related to current teaching practices and teacher’s recommendations
is given below.
Table 14: Sign Language Skills of HIC and their Teachers
Teacher’s sign
language level
f % Children’s sign
language level
f %
Limited
Able
Skillful
No response
5
55
42
5
4.6
51.4
39.2
4.6
Cannot
Limited
Skillful
No response
6
33
60
8
5.6
30.8
56.0
7.4
Total 107 100 Total 107 100
As the above table shows, 39% teachers were skilful in sign language and 51%
were able enough to communicate through sign language. Whereas 4% teachers
considered themselves as limited users of sign language and 4% did not enter their
proficiency in sign language. Most of the HIC i.e. 56% were skilful in the use of sign
147
language, as reported by the teachers. 30% HIC were having limited proficiency in sign
language and 5% were not able to communicate via signs. 6.1% entries by the teachers
were missed.
Table 15: HIC’s Ability to Understand Specific Topic when Communicated by only
Speech or only Signs
Using speech only f % Using Signs only f %
Don’t Understand
Understand Partially
Understand fully
No response
12
56
33
6
11.2
52.3
30.8
5.6
Don’t Understand
Understand Partially
Understand fully
No response
1
35
64
7
0.93
32.7
59.8
6.5
Total 107 100 Total 107 100
The teachers reported that 30% children would comprehend ideas of any topic of
discussion fully if only speech is used, 52% would understand the matter partially and
only 11% would not understand the topic details. 5% teachers did not comment on the
expected success rate of speech only mode of communication with HIC. In view of the
teachers of HIC, 59% HIC would comprehend the topic details fully if only signs were
used and 32% HIC would understand the topic partially.
148
Table 16: Current Mode of the Communication during Teaching and Teacher’s
Recommendations
Communication f % Teaching Method f %
Sign Only
Sign and Speak
No response
5
97
5
4.6
90.6
4.6
Aural approach
Total communication
Both
No response
24
37
11
35
22.4
34.5
10.2
32.7
Total 107 100 Total 107 100
The prevailing methodology of teaching was undoubtly total communication as
90% teachers reported this. A small number i.e. 4% were still using only signs during
teaching and 4% did not mention the mode of communication during teaching. 22%
teachers proposed the use of aural approach for communication and teaching HIC but
34% teachers recommended continuing the use of total communication. 10% teachers
recommended use of both approaches and 32% did not respond to this item of
questionnaire.
149
Table 17: Teachers’ Recommendations about the Special Needs of HIC
Aural rehabilitation f % Curriculum and Vocational
Training
F %
Listening skill
Development
Provision of Hearing
Aid
Both
No response
13
28
8
58
12.1
26.1
7.4
54.2
Curriculum Development
Vocational Training
Both
No response
8
33
22
44
7.4
30.8
20.5
41.1
Total 107 100 Total 107 100
It is clear from the above table that 12% teachers recommended to focus on
listening skill development, 26% teachers gave importance to provision of hearing aids
and 7% recommended both. But 54% teachers did not comment on this aspect of aural
rehabilitation. Similarly, 7% teachers identified the need in curriculum development,
30% highlighted the need of vocational training and 20% gave equal importance to
curriculum development and vocational training needs. 41% teachers did not comment on
the requirements of these items for HIC.
150
4.1.2 PARENT’S QUESTIONNAIRE
Out of 495, total 308 questionnaires were filled by parents or guardians of HIC.
Their analysis is as under.
4.1.2.1: Demographic Data:
Data analysis of child’s demographic information is given below.
Table 18: HIC’s Class and Age Group
Child’s Class F % Child’s Age f %
Preschool
Primary
Middle
High
Higher secondary
No response
91
79
34
83
13
8
29.5
25.6
11
26.9
4.2
2.6
3-6
7-9
10-12
12-14
15 and above
No response
12
68
28
31
141
28
3.8
22
9.0
10.0
45.7
9.0
Total 308 100 Total 308 100
As the above table shows, parents’ questionnaires were having diversity of HIC
belonging to different age ranges and class. Thus a valuable data about parent’s specific
experiences and personal views related to different age groups of HIC was obtained.
151
Table 19: Gender and Disability other than Hearing Impairment of the HIC and
Incidence of Hearing Impairment in Family
Gender f % Other disability f %
Male
Female
HIC with other
Disability
125
183
24
40.6
59.4
7.7
father
mother
brother
sister
any other
12
10
76
70
26
3.8
3.2
24.6
22.7
8.4
The table shows there were 59% girls as compared to the 40% boys and only 7%
HIC were having other disability also. In total, 62.9% HIC were having the same
disability in their families. The most common deaf family members were the siblings of
HIC.
152
Table 20: Educational Level of the Parents of HIC
Father’s
education
f % Mother’s
education
f %
Illiterate
Below matric
Matriculation
Intermediate
Bachelor
Master
No response
28
57
72
42
37
15
57
9.1
18.5
23.4
13.6
12
4.9
18.5
Illiterate
Below matric
Matriculation
Intermediate
Bachelor
Master
No response
56
82
49
14
13
9
85
18.2
26.6
15.9
4.5
4.2
2.9
27.6
Total 308 100 Total 308 100
It is evident from the table that 9% fathers and 18% mothers of HIC were
illiterate. 18% fathers and 26% mothers were under matriculation. 23% fathers and 15%
mothers were with a certificate of matriculation 13% and 12% fathers were having
intermediate and bachelor’s degree respectively.
153
Table 21: Professional Level of the Parents of HIC
Father’s job f % Mother’s job f %
Skilled /labour
Govt. Servant
Private Job
Abroad
No response
113
81
22
4
88
31.6
26.2
7.8
1.6
32.8
Skilled /labour
Govt. Servant
Private Job
House Wife
No response
3
13
3
151
138
1.0
4.2
1.0
49
44.8
Total 308 100.0 Total 308 100
The table shows, 31% fathers of HIC were belonging to the low skilled profession
and 26% were in government jobs. Most of the mothers, i.e. 49% were housewives. More
than one third of the parents did not tell their nature of the job or ways of earning.
154
Table 22: Number of Siblings and Monthly Income of the HIC Family
No. of siblings f % Monthly Income f %
Zero
One
Two
Three
Four
Five
Six
More than 6
No response
2
16
45
62
74
50
32
20
7
0.6
5.2
14.6
20.1
24.0
16.2
10.4
6.5
2.2
Up to 5,000
Up to 10,000
Up to 15,000
Up to 20,000
Up to 25,000
Up to 30,000
Up to 50,000
More than 50,000
No response
7
80
82
43
22
25
22
5
22
2.3
26
26.6
14
7.1
8.1
7.1
1.6
7.1
Total 308 100 Total 308 100
As the above table shows, 24% HIC families were having four children, 20%
were with three children and 16% were having five children at home. 26% families of
HIC were with earning either of only up to ten thousand or fifteen thousand only.
155
Table 23: When did the Child Become Deaf and when was he/she Diagnosed as
Deaf?
When become deaf f % When Diagnosed f %
By Birth
Birth – 6 Week
6 Week to 6 Month
7-11 Months
12-24 Months
Above 2 years
No response
210
22
10
25
9
15
17
68.4
7.2
3.3
8.1
2.9
4.8
5.5
At Birth
At 6 –Weeks
At 6- Months
At 1 - year
At 18 – Months
At 2 years
No response
20
4
3
6
2
6
267
6.5
1.3
1.0
2.0
0.7
2.0
86.9
Total 308 100 Total 308 100
As the above table shows, 68% HIC had congenital hearing loss (present at the
time of their birth). 86% parents of HIC did not report the exact age of diagnosis of the
disability perhaps due to their confusion about when it was confirmed to be having a HIC
in family.
156
4.1.2.2: Data About HIC’s Communication Level
Information about HIC communication style and competency is analysed below.
Table 24: Mother Tongue and Other Languages Used at the Home of HIC
Mother
tongue
f % Other Languages f %
Punjabi
Urdu
Other
No response
147
85
60
16
47.7
27.5
19.4
5.1
Different from mother tongue
Same as mother tongue
Sign language
No response
36
246
4
22
11.6
79.8
1.2
7.1
Total 308 100 Total 308 100
It is evident that Punjabi was predominantly main spoken language at the homes
of HIC with the highest percentage of 47.7% and Urdu was the second most spoken
language at home with percentage of 27.5%. 79.8% HIC families were using only one
language at home and 11% families were using languages other than mother tongue.
157
Table 25: Imitation Skills and Receptive Language of HIC
Repeat Sounds, words
and phrases
f % Understand what is
said to him
f %
No
Yes
No response
134
131
43
43.5
42.5
13.9
No
Yes
No response
70
206
32
22.7
66.8
10.3
Total 308 100 Total 308 100
As the table shows, 66% HIC had the ability to understand what was said to them
and 42% HIC could repeat either sounds or words or phrases spoken to them.
Table 26: Receptive Language Skills of the HIC
Point to Common objects
when asked
f % Follow
commands
f %
No
Yes
No response
42
234
32
13.6
75.9
10.3
No
Yes
No response
43
232
33
14.0
75.3
10.7
Total 308 100 Total 308 100
158
Data in the table revealed that almost three fourth of the HIC i.e. 75% had the
ability to point to the common objects like ball, baby, etc., when asked and the same
percentage could follow the simple commands given to them, as reported by their
parents.
Table 27: Correct Responses to Yes/ No and What/Where/When/Why Questions by
HIC
Respond as yes/no f % (Wh) questions f %
No
Yes
No response
50
207
51
16.2
67.2
16.5
No
Yes
No response
71
166
71
23.0
53.8
23.0
Total 308 100 Total 308 100
The above table shows 67% HIC were able to respond to the questions requiring
simple answers of yes or no and 53% could give elaborated answers of WH questions i.e.
what, when, where, why, who, etc. also.
159
Table 28: How Well HIC Could Communicate with the Parents?
Father f % Mother f %
v. poor
poor
average
good
v. good
No response
17
6
75
95
80
35
5.5
1.9
24.4
30.8
26.0
11.3
v. poor
poor
average
good
v. good
No response
17
5
51
98
107
30
5.5
1.6
16.6
31.8
34.7
9.7
Total 308 100 Total 308 100
Most of the HIC were very comfortable in communicating with their parents, as
most of the responses of the parents were falling between average and very good
communication level of the HIC.
160
Table 29: How Well HIC Could Communicate with the Siblings?
Brother f % Sister F %
v. poor
poor
average
good
v. good
No response
16
12
65
99
69
47
5.1
3.8
21.1
32.1
22.4
15.2
v. poor
poor
average
good
v. good
No response
18
7
54
80
90
59
5.8
2.2
17.5
25.9
29.2
19.1
Total 308 100 Total 308 100
The HIC were reported to be approximately equally at ease while communicating
with their siblings. Most of the HIC were having very good and good communication
standard with their sisters and brothers respectively.
161
Table 30: How Well HIC Could Communicate with the Teacher and Others?
Teacher f % Others f %
v. poor
poor
average
good
v. good
No response
20
5
43
75
112
53
6.4
1.6
13.9
24.3
36.3
17.2
v. poor
poor
average
good
v. good
No response
23
15
93
73
70
34
7.4
4.8
30.1
23.7
22.7
11.0
Total 308 100 Total 308 100
It is clear from the table that according to parents of HIC, 36% and 22% HIC
were having very good and 24% and 25% of HIC were having good communication with
teachers and other significant persons near to them respectively.
162
4.1.2.3: Data About Availability of Different Services to the Parents of
HIC
Parents were asked about the services they received during the last six months, at
the time of diagnosis of hearing impairment of their children and during primary school
years of HIC. Data about parent’s specific responses at these times is analysed below.
Table 31: Availability of Services of Different Professionals in the Last Six Months
Professional f % Professional f %
Teachers
Psychologist
SLT
176
76
86
35.2
15.2
17.2
audiologist
S. Worker
any other
79
40
42
15.8
8.0
8.4
Total Responses 499 100 %
Overall 499 responses were entered by 308 parents, as few of them mentioned the
availability of more than one professional to them in the last six months. The table shows,
35% parents of HIC reported the availability of special education teachers for the deaf.
After teachers, the most available persons in the last six months were speech therapist,
audiologist and psychologists. 13% parents reported the availability of social case worker
or any other helping them for their HIC.
163
Table 32: HIC’s Parental Demand of Recent Contact with Whom?
Wish Contact f % With Whom f %
No
Yes
No response
66
163
79
21.4
52.9
25.6
Doctor
Teacher
psychologist
Audiologist
S. Therapist
S. Worker
No response
9
15
8
52
44
1
34
5.5
9.2
4.9
31.9
26.9
0.6
20.8
Total 308 100 Total 163 100
The above table shows, 52% parents of HIC demanded the provision of services
of different professionals to their children. Professionals with highest demand were the
audiologist and speech therapist. Still, 20% parents were not sure of any specific services
in need.
164
Table 33: Availability of Support from Doctors When Deafness was Diagnosed
Paediatrician f % ENT f %
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
55
22
22
16
48
145
17.9
7.1
7.1
5.1
15.6
47.0
v. much Sup
Much Sup
Average Sup
Less Supp
v. Less Supp
No response
39
22
35
22
49
141
12.7
7.1
11.3
7.1
15.9
45.7
Total 308 100 Total 308 100
The table shows, 17% and 7% parents reported very much and much support
obtained respectively from the child specialist while 12% and 7% parents reported the
same from the ENT specialists around the time when deafness was diagnosed. 15%
parents of HIC reported very less support from both child and ENT specialist
respectively. But nearly half of the parents did not respond about the services of the
doctors available to their children at that time.
165
Table 34: Availability of Support from the Teachers and Psychologist When
Deafness Was Diagnosed
Teacher f % Psychologist f %
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
35
18
29
20
69
137
11.3
5.8
9.4
6.4
22.4
44.4
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
47
18
22
16
41
164
15.3
5.8
7.1
5.2
13.3
53.2
Total 308 100 Total 308 100
The table shows, 11% and 15% parents reported very much and 5% reported
much support obtained from teachers and psychologist respectively around the time when
deafness was diagnosed. 22% and 13% reported very less support from these
professionals respectively. But 44 and 53% parents did not respond about applicability of
these services to their children at that time.
166
Table 35: Availability of the Support from Educational Audiologists and Speech
Therapists When Deafness Was Diagnosed
Ed. Audiologist f % Speech therapist f %
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
46
6
17
8
57
174
14.9
1.9
5.5
2.6
18.5
56.5
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
37
12
15
12
47
185
12
3.9
4.9
3.9
15.3
60
Total 308 100 Total 308 100
It is clear from the table that 14% and 12% parents reported very much support
obtained and 18 and 15% reported very less availability of support from educational
audiologists and speech therapist respectively around the time when deafness was
diagnosed. But 56 and 60% parents did not respond that the services of an audiologist and
speech therapist were available to their children, at that time.
167
Table 36: Availability of the Support from Family and Any Other Person, When
Deafness Was Diagnosed
Family f % Any other f %
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
36
7
16
7
32
210
11.7
2.3
5.2
2.3
10.4
68.1
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
27
3
3
1
27
247
8.8
1.0
1.0
0.3
7.5
80.8
Total 308 100 Total 308 100
The table shows, 11% and 8% parents reported very much support obtained from
family members and any other person not mentioned earlier like friends etc., around the
time when deafness was diagnosed. And 10% and 7% parents reported very less
availability of support from these ones respectively. Again 68 and 80% parents did not
respond about applicability of these services to their children at that time.
168
Table 37: Availability of the Support from Social Case Worker, When Deafness
Was Diagnosed and Parental Views about HIC Needs Neglected by Hospitals/
Schools
Social case worker f % Neglected or not f %
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
39
5
7
7
31
219
12.6
1.6
2.3
2.3
10.0
71.1
No
Yes
No response
10
67
231
3.24
21.7
83.9
Total 308 100 Total 308 100
The table shows, 12% parents reported very much support, 2% reported average
support and 10% reported very less availability of support obtained from a social case
worker around the time when deafness was diagnosed. 71% the parents did not respond
about applicability of these services to their children, at that time. 21% parents consider
that their child’s special needs were neglected by the hospitals and schools, whereas 84%
parents did not respond to this important item of the questionnaire.
169
Table 38: Parental Wish to Have Availability of the Support from Different
Professionals at the Time of Diagnosis
Want support f % From whom F %
No
Yes
No response
118
77
113
38.3
25
36.7
Doctor
Teacher
Psychologist
Audiologist
SLT
No response
5
6
3
27
31
5
6.4
7.7
3.8
35
40.2
6.4
Total 308 100 Total 77 100
The table shows, 25% parents expressed their wish of availability of some
services at the time of diagnosis of hearing impairment and the most demanded
professionals, at that specific time period were speech therapist (40%) and audiologist
(35%).
170
Table 39: Availability of the Support from Doctors During Primary School Years of
the HIC
Paediatrician f % ENT f %
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
42
12
16
10
31
200
13.6
3.8
5.1
3.2
10
64.9
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
36
17
18
16
40
181
11.6
5.5
5.8
5.2
13
58.7
Total 308 100 Total 308 100
The table shows, 13% and 11% parents reported very much support, obtained
from child specialist and ENT specialist during primary school years of the HIC. 10 and
13% reported very less support from the child specialist and ENT specialist respectively.
But 64 and 58% parents did not respond about applicability of the services of both
professional, to their children at that time.
171
Table 40: Availability of the Support from the Teachers and Psychologist During
Primary School Years of HIC
Teacher f % Psychologist f %
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
31
19
33
26
105
94
10.1
6.2
10.7
8.4
34.1
30.5
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
39
17
20
19
42
171
12.7
5.5
6.5
6.2
13.6
55.5
Total 308 100 Total 308 100
The table shows, 10 and 12% parents reported very much support obtained from
teachers and psychologist respectively during primary school years of HIC. 10 and 6%
reported average support from these professionals respectively. And 34% and 13%
reported very less support obtained from these professionals. But 30% and 55% parents
did not respond about applicability of these services to their children at that time.
172
Table 41: Availability of the Support from Educational Audiologists and Speech
Therapists During Primary School Years of HIC
Ed. Audiologist f % Speech therapist f %
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
31
12
12
18
61
174
10.1
3.9
3.9
5.8
19.8
56.4
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
28
13
14
16
52
184
9.1
4.2
4.5
5.2
16.9
60
Total 308 100 Total 308 100
The table shows, only 10% and 9% parents reported very much support obtained
from educational audiologists and speech therapist respectively during primary school
years of HIC. And 19% and 16% parents reported very less availability of support from
both of these professionals. But 56% and 60% parents did not respond about applicability
of these services to their children at that time.
173
Table 42: Availability of the Support from Family and Any Volunteer, During
Primary School Years of HIC
Family f % Any other f %
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
34
11
12
5
34
212
11
3.6
3.9
1.6
11
68.7
v. much Sup
Much Sup
Average Sup
Less Supp
v. less Supp
No response
18
4
3
2
33
248
5.8
1.3
1.0
0.6
10.7
79.5
Total 308 100 Total 308 100
It is evident from the table that 11% and 5% parents reported very much support
obtained from family members and any other person not mentioned earlier like friends
etc. during primary school years of HIC. 11% and 10% parents reported very less
availability of support from these ones respectively. Again 68% and 79% parents did not
respond about applicability of these services to their children at that time.
174
Table 43: Availability of Support from Social Case Worker, During Primary School
Years of HIC and Child’s Academic Progress in School
Social case worker f % Has child repeated any
grade/ class
f %
v. much Sup
Much Support
Average Sup
Less Support
v. less Sup
No response
32
6
6
4
41
219
10.3
2
2
1.3
13.3
71
Yes
No
No response
10
272
25
3.2
88.3
8.1
Total 308 100 Total 308 100
The table shows, only 10% parents reported very much support obtained from a
social case worker during primary school years of HIC and majority i.e. 13% 4% reported
very less support him. And 71% parents did not consider these services applicable to their
children at that time. Only 3.2% HIC had repeated classes/grades as reported by their
parents and 88% children were passing through different grades continuously.
175
4.1.2.4 Parental satisfaction from available support from the
professionals
Table 44: Parental Wish to Have Availability of the Support from Different
Professionals, During Primary School Years of HIC
Want support f % From whom f %
No
Yes
No response
Total
94
104
110
308
30.5
33.7
35.7
100
Audiologist
SLT
All others
No response
29
31
12
32
27.8
29.8
11.5
30.7
Total 308 100 Total 104 100
The above table shows, 33% parents expressed their wish of availability of
services of different professionals during primary school years of HIC and the most
demanded professionals during that specific time period were the speech therapist and
audiologist. 30% parents felt the requirement of professionals but did not specify which
one.
176
Table 45: Summary of Parental Opinion about Problems Faced by them and Areas,
Demanding Immediate Attention from the Government
Parents facing problems Parents demanded action from government
• They had missed the
excellence of speech therapist and
audiologist.
• Child is a position holder, but
can’t write a single line on his
own.
• Lack of attention from
teachers.
• Lack of money.
• Lack of moral support from
family
all HIC could not get a cochlear
implant
• Financial support for medical
intervention
• Hearing Aids AND Transport
• Development of institute
• Provision of books
• More teachers for deaf
• Appointment of a speech therapist and
an audiologists
• Appropriate treatment
Only 23% parents attempted to answer the open-ended questions of the
questionnaire related to the problems faced by them and their demand from the
177
government. The above table shows a consolidated view of their problems and their
requirements.
Table 46: Summary of the Parental comments about current system and
recommendations
Parental comments Parental recommendations
• Educational methodology is not
correct.
• The schools are not neglecting
HIC, but the hospitals are doing so.
• Provision of milk had been
stopped.
• Facilities are required for mental
• and physical growth of the child.
• They missed the excellence of
SLT.
• Employment opportunities are
• scarce.
• Hospitals are not treating HIC
properly.
• Hearing aids are required
• Speech therapy and auditory
facilities are needed
• Focus on Job placement
• Provision of aids from school
• Transportation Facilities are
scarce, so enhance them
• Free monthly medical checkup in
all hospitals
• Moral focus on moral values in
studies
• Separate doctors for special
persons in hospitals
178
4.1.3 SPEECH THERAPIST’S QUESTIONNAIRE
Only twelve questionnaires were received back due to the shortage of the
professionals in the department. Seats of SLT’s were previously allocated only in the
centres of the Punjab government and in institutes previously run by the Federal
Government. Many seats of SLT’s were vacant as reported by the Heads of the Institutes.
A valuable data about 192 HIC was obtained through these questionnaires.
4.1.3.1: Demographic Data of SLT’s:
Table 47: Age, Gender and Employment Status of the Speech Therapist
Age range and gender f % Nature of employment f %
26-30
31-35
Male
Female
8
4
2
10
66.7
33.3
16.7
83.3
Contract
Regular
Posted as SLT
Not as SLT
2
10
9
3
16.7
83.3
75
25
As the above table shows, majority of speech therapist i.e. 66% were falling in
26-30 years age group and 33% in 31-35%. The profession of SLT was dominated by
female gender( 83%).25% speech therapists were employed on contract basis and 75%
were appointed on permanent basis. Majority of speech therapist i.e. 83% were employed
in the same cadre and a small proportion were appointed as other than speech therapist.
179
Table 48: Educational level and Experience of the Speech Therapist
Qualification f % Experience f %
Masters
M. Phil
Ph. D
8
2
2
66.7
16.7
16.7
1-3 years
7-9 years
10
2
83.3
16.7
Total 12 100 Total 12 100
As the table shows, 66% SLT were having a master’s degree and 16% were
having M. Phil and 16% were with Ph. D degree. 83% SLT were having 1-3 years of
experience and 16% were having experience of 7-9 years.
4.1.3.2: Data of HIC:
Table 49: Age Group of HIC and Provision of the Speech Therapy Sessions per
Week
Class of HIC f % Sessions/ week f %
Preschool
1-2 class
3-5 class
5-10 class
No entry
66
54
10
24
38
34.4
28.1
5.2
12.5
19.8
1-2
3-4
5-6
112
74
6
58.4
38.5
3.1
Total 192 100 Total 192 100
180
The above table shows, most of the HIC, receiving speech therapy belonged to the
junior classes i.e. 34% were in preschool years and 28% were in 1-2 class. 20% classes of
HIC were not entered by the speech therapist. 58% children were receiving therapy for 1-
2 days per week and 38% were receiving therapy for 3-4 days per week. Only 3% HIC
were receiving intensive therapy from the speech therapists.
Table 50: Provision of the Hearing aid, Hearing Aid Type and Use of Aid by
HIC
Provision and type of
aid
F % Use of aid f %
Not provided
Provided
Body Worn
B.T.E
74
118
66
52
38.5
61.4
55.9
44
Regular
Not regular
Comfortable
Not comfortable
16
102
20
98
13.5
86.4
16.9
83
It is evident from the table that the majority of HIC students, i.e. 61% selected by
SLT’s for therapy were having the hearing aid whereas, 38% HIC were not provided with
amplification. And out of those having the access to amplification devices, 55% were
having body worn and 44% were using behind the ear hearing aid. Out of 118 HIC
provided with hearing aid only 13% were regularly using their aid where as the majority
181
of HIC i.e. 86% were not regularly using their aid to get benefit from it. The reason
behind irregular use of hearing aid seems to be that only 16% HIC were comfortable and
83% HIC were not comfortable when using their hearing aid.
4.1.3.3 Auditory profile of HIC
Table 51: The Listening Skills of the HIC
Listening task f of (can) % f of can’t %
Detect environmental sound 104 54.1 88 45.8
Detect speech sound 116 60.4 76 39.5
Localise sound 121 63.0 71 36.9
Monitor aid 84 43.7 108 56.2
Detect source of music 4 2.0 188 97.9
Discriminate between loud and soft
sound
84 43.8 108 56.25
Discriminate two persons voices 4 2.0 188 97.9
Identify name 86 44.7 92 47.9
Identify body parts 86 44.7 92 47.9
Identify colours 36 18.7 92 47.9
The table shows, 54% HIC were able to detect environmental sounds as reported
by SLTs. 60% HIC were able to detect speech sounds. 63% HIC were able to localise the
182
incoming loud sounds and 44% HIC could monitor the performance of their amplification
aid and the majority of HIC don’t know how to monitor it. 98% HIC could not detect the
source of music if present in the environment. And 56% HIC could not discriminate loud
and soft sounds while 44% could do so. 98% HIC could not discriminate between the
voices of two persons like teacher and students. 44% HIC could identify the body parts
and their names when called, 47% could not do so and 7% HIC’s information about
identification of body parts and name is not available. Out of 40% HIC able to hear
speech sounds only 18% could identify colours, 47% could not and 33% SLTs did not
mention the child’s level of recognition of colours.
Table 52: Identification of Speech Sounds and Comprehension of Connected Words
by the HIC
Identify sounds f % Comprehension f %
Stops
Nasals
No response
92
86
14
47.9
44.8
7.3
1-2
3-4
More than 4
No response
102
4
72
14
53.1
2.1
37.5
7.3
Total 192 100 Total 192 100
The table shows, 48% HIC could identify the stop sounds in words and 45%
could identify the nasals. 53% HIC could repeat 1-2 words and 37.5% could repeat four
word sentence. Again 7% entries were not made by speech therapists.
183
4.1.3.4 practices of speech therapists
Table 53: Diagnosis of Speech, Language and Listening Skills of the HIC
Assessment f % Nature of Test f %
Annual
Bi-annually
6
6
50
50
Case history
Speech and language
assessment
Auditory assessment
10
8
4
83.3
66.6
33.31
The above table shows, 83% SLTs were taking case histories of HIC, and 17%
were not practising to take case histories of all HIC in schools. 66% SLTs were taking
detailed speech and language assessment of HIC and 17% were not taking the
assessment. 17% did not respond to this item of the questionnaire. 50% SLTs were
keeping annual and the same number of SLTs were keeping records of 4-6 month
progress record of HIC. 33% SLTs were not maintaining the record of either 4-6 monthly
or annual progress report of HIC. 7% did not check these both items again. 33% SLTs
were taking auditory assessments, including aided functional auditory profile of each
child. And the majority of the SLTs were not giving attention to this important area of
assessment of HIC.
184
Table 54: Record Keeping by the Speech Therapist
Record keeping f % Complete files F %
Current target
Previous targets
No response
6
4
2
33.3
33.3
16.7
51-70%
71-90%
Above 90%
No response
2
2
4
4
16.7
16.7
33.3
33.3
The above table shows, 33% SLT’s were maintaining the record of all previous
speech therapy targets and 50% were maintaining the record of all current targets of
speech therapy. 33% speech therapists did not tick the relevant answer to this item. Only
33% speech therapists had completed assessment records of each child. While 33% did
not mention their efforts of record keeping.
4.1.3.5: Provisions Available to SLTs:
Data regarding different facilities provided to the speech therapist are summarised
next.
185
Table 55: Available Provisions to the Speech Therapists
Provision of items f % Provision of items f %
Sound treated test
booth
4 33.3 Speech therapy clinic 8 66.6
C.D. Player 4 33.3 Material for
intervention
10 83.6
Computer 2 16.6 HATS 4 33.3
Material for diagnosis 6 50 Furniture 8 66.6
The above table is used to display the equipment/material provided to the SLT. It
is evident from the above table that 50% SLTs were not provided with sound treated test
booth, while 33.3% speech therapists were availing this facility. 16.7% did not respond to
this question. 67% SLTs were provided with clinical speech therapy room while 33%
were using ordinary classroom and furniture. The majority of the SLTs i.e. 83% were
having the materials required for intervention services. While 17% did not respond to the
item. 67% SLTs were having appropriate furniture for therapy. 50% SLTs were provided
with amplification instruments and 33% were not whereas 16% did not respond to this
item. The majority of the SLTs i.e. 83% were not provided with a sound-level metre and
17% did not answer this item again. For recorded assessment of speech and language,
only 33% SLTs were having facilities such as C.D player whereas, 50% were not
provided with these facilities. 16% SLTs did not respond. The majority of the SLTs i.e.
186
67% were not having P.C for record keeping etc. 16% were having P.C and 13% did not
answer to the item. The majority of the SLTs i.e. 67% were not provided with necessary
equipments and instruments for assessing HIC children while 33% did not mention the
provision of equipments. 50% SLTs reported the provision of test materials for speech
and language evaluation, 33% were not provided and 17% did not respond to this item of
the questionnaire.
Table 56: Analysis of the Prevailing Situation and Recommendations by SLTs about
Future Needs
Item Good Average Less Required
more
Collaboration with teachers 50 50 - 83
Communication with teachers 16 33 33 83
Parental guidance and support 16 33 33 83
Support from the administration 33 33 33 83
Teachers training facilities 16 33 33 67
Provision of hearing aid 16 - 67 83
Auditory training 16 16 33 83
SLT training 33 - 33 67
Workload 50 33 - 50
187
The above table gave a consolidated view of the speech therapists’ comments
about the prevailing atmosphere in special schools and recommendations in percentage
directly. 50% SLTs reported good and 50% reported average level of collaboration with
teachers. 33% reported either average or less communication level with parents, parental
guidance and counselling and teacher training facilities. 33% SLTs reported either better
or less support from the administration and training facilities for SLTs. The majority of
SLTs reported very less provision of hearing aid to the HIC and auditory training
facilities. As far as speech therapy workload was concerned, the majority of SLTs felt
over burdened with the work and 33% reported average level of workload.
4.1.4 PRINCIPAL’S QUESTIONNAIRE
Only eleven questionnaires were received back despite numerous telephonic
contacts and requests from the researcher. Teachers’ and parents’ questionnaires were
collected by the focal persons allocated but, they could not make the head’s of the same
institutes to fill the forms related to the Heads of the institutes. Moreover the received
questionnaires were not filled properly as, most of the items were open-ended questions
inquiring details and the principals gave brief responses only. Thus a list of questions
considered important was prepared and principals were contacted again telephonically to
get a response. Analysis of the data obtained through questionnaires and telephonic
probes is analysed here.
188
4.1.4.1: Demographic Data
Table 57: Age and Gender of the Principals
Age range f % Gender/ Education level f %
26-30
31-35
46-50
55-60
2
2
7
3
14.2
14.2
50
21.4
Male
female
Masters
M. Phil
4
10
10
04
28.5
71.4
71
28.5
Total 14 100 Total 14 100
As the above table shows, the majority of the principals i.e. 50% were falling in
46-50 years age group and 14% in 26-30 as well as 31-35 age group. The profession of
the principal ship in special education is dominated by female gender having percentage
of 71% and same percentage was holding a Masters degree. 28% principals had M. Phil
degree also.
189
Table 58: Experience and the Nature of Employment of the Principal
Experience f % Nature of Employment f %
1-5 years
6-10 years
11-15 years
16-20 years
21-25 years
Above 25
4
1
2
1
4
2
28.5
7.1
14.2
7.1
28.5
14.2
On contract
permanent
posted as principal
other than principal
0
14
12
2
0
100
85.7
14.2
Total 14 100 Total 14 100
As the above table shows, 28% principals were having 1-5 years of experience
and 28% were having the experience of 21-25 years. 85% principals were appointed in
the same cadre whereas 14% employees of me other cadres were performing duties of
principals. 100% persons performing duties of principal were employed on a permanent
basis.
190
4.1.4.2: Data Regarding Available Provisions for Different Goals of
Educating HIC
Table 59: Provisions for Academic Development of HIC
Available Activities/areas f % Available provisions f %
Languages
Numeracy
G. knowledge
Science
Religious
14
14
14
13
13
100
100
100
92.8
92.8
Subject teachers
Books
A.V aids
Financial aid for note
books etc
12
13
14
13
85.7
92.8
100
92.8
The table shows that the teaching of languages (English and Urdu) and
mathematical skill were covered in all Punjab special education schools/institutes
catering the special needs of HIC. In some schools, especially in primary classes Science,
Social Studies and Islamiat were taught as a single subject under the name of general
knowledge. Although all special schools were having special education teachers, but their
quantity varies a lot. There was a dearth of specially trained teachers in numerous
schools, especially in special education centres of Punjab, where in average, there were 2-
3 teachers for 60-80 HIC. All special education institutions, run by Punjab government
were providing free books, transportation, uniform and scholarship to all special children
studying there.
191
Table 60: Provisions for Vocational Development of HIC
Available
Activities/areas
f % Available provisions F %
Drawing/painting
Tailoring
Computers
Electrical
Home economics
14
12
13
1
3
100
85.7
92.8
7.1
21.4
Computer labs
Art rooms
Kitchen
Electrical workshop
Sewing machines
Vocational teacher
Financial assistance for
practising material
6
5
5
1
9
9
0
42.8
35.7
35.7
7.1
64.1
64.1
0
A limited range of vocational subjects was reported by the principals of special
schools. Although vocational subjects were taught in all institutions, but availability of
vocational teacher was subject to availability of the seat of vocational teachers in these
schools. All special education centres, dealing with all four disabilities, run by the Punjab
government, don’t have the seat of vocational teacher, but the students have to appear in
two vocational subjects in the board examinations. Moreover, availability of computer
labs and instructors, sewing machines, art room and practising material were reported to
be in deficiency, by the Heads of the institutions. All HIC had to arrange for costly
vocational material for practice.
192
Table 61: Provisions for Speech and Language Development of HIC
Available Activities/areas f % Available provisions f %
Listening skills
Speech skills
Reading skills
Oral Language skills
Written language
development
Audiological assessment
Selection and fitting of aid
14
14
14
14
14
4
1
100
100
100
100
100
28.5
7.1
Hearing aids
audiologist
speech therapist
auditory training
facilities/material
evaluation equipments
and assessment
materials
sound treated rooms
Financial aid for
amplification
7
4
8
8
4
3
0
50
28.5
57.1
57.1
28.5
21.4
00
The above table shows the summary of activities targeted at the institutions, as
reported by their Heads. All three important aspects of rehabilitating HIC i.e. listening,
speech and language development were considered as the goals of educating HIC, but the
provisions available for these targeted areas were falling behind the average level. For
audiological assessment and diagnosis, the majority of the HIC had to visit hospitals
either because of non-availability of professional audiologists, having calibrated
audiometers or because of poor assessment done by different professionals of the
193
institutions, not primarily appointed to the job of diagnosis of hearing loss and updating
the audiological assessment. Teachers, speech therapist and nursing assistant were doing
audiometry of HIC on demand only. Moreover the equipment for assessment, hearing
assistance technology, sound treated test rooms, classroom acoustics considerations, etc.
were not given due importance by the Heads of the institutes due to non-availability of
budgetary allocation for this purpose. A small number of hearing aids, F.M system, and
Radio aids were donated to HIC, a few years ago and a few HIC have provided with a
cochlear implant, but due to non-availability of educational audiologists, speech therapist
or proper follow-up by these professionals, HIC were not getting benefits from these
efforts.
194
Table 62: Provisions for Co-curricular Development of the HIC
Available
Activities/areas
f % Available provisions F %
Games
dramas
drawing/painting
Scouting/ girl guide
recreational tours
parties
competitions
14
14
14
2
14
14
14
100
100
100
14.2
100
100
100
Physical instructor
Sports ground
auditorium
Art teacher
transport
Financial aid
5
12
7
10
14
2
35.7
85.71
50
71.4
100
14.2
The above table shows the range of co-curricular activities available for HIC in
Punjab. Only scouting/girl guide activity is not common in special schools. All other
activities mentioned in the table were equally popular, in special schools. Facilities for
co-curricular activities, provided to HIC vary in different institutes. The older the
institute, the more were the facilities. Although financial assistance was provided to the
least extent and there was also lack of professional physical trainers/ coaches in special
schools, but there were numerous remarkable achievements of HIC, as reported by the
Heads of the institutes. Most frequent activity available to HIC was the educational cum
recreational trips. Even the HIC studying in schools without sports ground, hall, physical
education and art teacher were enjoying tours of different historical places.
195
Table 63: Provisions for Physical and Emotional Health and Development
Activities f % Available provisions f %
Medical checkups
treatment facilities
referral
stress management
guidance and counselling
1
1
14
14
14
7.1
7.1
100
100
100
Medical specialist
ENT specialist
Medicines
Psychologist
Social case worker
Filtered water
Financial aid
0
0
4
6
6
8
0
00
00
28.5
42.8
42.8
57.1
00
The Heads of the institutes reported the availability of the psychologist or social
case worker for emotional and psychological well-being of HIC. As far as physical health
was concerned, all institutions reported the existence of referral to the hospitals and
provision of medicines was restricted to first aid level. Only one institute run by the
Ministry of Defence reported the free medical and treatment facility available to all HIC
studying there. Even clean, filtered water was not available to all HIC studying in special
schools of Punjab.
196
Table 64: Provisions for Aural Rehabilitation, Mainstreaming and Professional
Development of the Staff
Activities f % Available provisions F %
Awareness campaign
Contacts with Heads of
normal schools
HIC mainstreamed
Follow-ups by special
teachers
In-service training of staff
Parental training
PTAs
0
0
2
2
14
2
14
00
00
14.2
14.2
100
14.2
100
Audiologists
Speech therapist
Psychologist
Coordinator
Special teacher
Financial aid
Screening camps
Parental guidance/
training material
4
8
6
0
14
0
0
2
28.5
57.1
42.8
00
100
00
00
14.2
As reported by the Heads of special schools for HIC, all of the institutions were
having facility for in-service training of its staff. There was the existence of parent
teacher associations in all schools to deal with the issues like shortage of teaching and
non-teaching staff, etc. A weak coordination was observed between Heads of special and
the mainstream schools as, most of the HIC were retained by special schools and the total
number of HIC, mainstreamed so far by these special schools was negligible. It was
reported by the principals that awareness about hearing loss and its debilitating effects on
the lives of HIC and parental training for speech and hearing skill development was not
considered to be the responsibility of the institutes.
197
4.1.5 AUDIOLOGIST’S QUESTIONNAIRE
4.1.5.1: Demographic Data
Only seven questionnaires were received back, but only one was filled by
professional audiologist and other six questionnaires were filled by teachers, performing
duties of an audiologist, out of which only one was having a training certificate in
audiology.
Table 65: Age, Gender and Professional Qualification of the Audiologist
Age range f % Gender/Qualification f %
26-30
36-40
Above 55
1
4
2
14.3
57.1
28.6
Male
female
Diploma
Masters
5
2
1
1
71.4
28.6
14.3
14.3
Total 7 100 Total 7 100
As the above table shows, the majority of the audiologists i.e. 57% were falling in
36-40 years age group and 28% were above 55 years old. The profession of audiology is
dominated by e male gender in the school. 14% audiologists were having master’s degree
in the field of audiology and same percentages were having training from the children
hospital.
198
Table 66: Experience and Nature of Employment of the Audiologists
Experience f % Nature of employment f %
1-3 years
4-6 years
7-9 years
No response
3
1
1
2
42.9
14.3
14.3
28.6
Contract
permanent
appointed audiologist
other than audiologist
2
5
1
6
28.6
71.5
14.3
85.7
Total 7 100 Total 14 100
The above table shows, 42% audiologists were having 1-3 years of experience
and 14% were having an experience of 4-6 as well as 7-9 years. 71% audiologists were
employed on a permanent basis and 28% were appointed on contract basis. Only one was
professional audiologist and others were employed in other cadre (senior teacher) and
performing duties of an audiologist.
199
4.1.5.2 Available Provisions and practices of audiologist
Table 67: Provisions, Available to the Audiologists
Provision of items f % Provision of items f %
Sound treated test booth
Clinical audiometer
Portable audiometer
Otoscope
3
3
2
2
42.9
42.9
28.6
28.6
HATS
Ear mould materials
Sound-level metre
Hearing aid analyser
Computer
2
2
1
2
3
28.6
28.6
14.3
28.6
42.9
The above table is used to display the equipment/material provided to the
audiologist. It is evident that 42% audiologists were provided with sound treated room,
clinical audiometer and computer for record keeping. 28% were having portable
audiometers, Otoscope, ear mould material and hearing aids to be used with children.
14% were having a sound-level meter also. All of the audiologists reported the non-
availability of visual reinforcement audiometry equipment, clinical and portable acoustic
immitance equipment, electro physiological equipment for BERA, test material for
screening and evaluating speech and language skills, material necessary for providing
direct and indirect intervention services and sterilisation equipment.
200
Table 68: Determination of the Nature and Degree of Hearing Loss
Assessment f % Nature of the Test f %
On admission
Bi-annually
functional listening
measurement
auditory development
measurements
5
2
1
1
71.4
28.6
14.3
14.3
Case history
Pure tone audiometry
Comfortable and
uncomfortable loudness level
Play audiometry
Speech audiometry
5
7
1
2
3
71.4
100
14.3
28.6
42.9
The above table shows, 71% audiologists were taking audiological tests of HIC
only at the time of admission to the school and only 28% audiological diagnostic
practices were updated bi-annually. The analysis of different types of tests to determine
the nature of hearing loss shows that all of the audiologists were prone to take pure tone
audiometry alone and 71% were also taking case histories of HIC. 42% audiologists take
speech audiometry test and 28% were opting play audiometry with young children.
Determination of most comfortable and uncomfortable loudness level, functional
listening skill measurement and auditory skill development measurements were also
taken by the audiologist but up to a much lesser extent.
201
Table 69: The Provision of Different Intervention Services by the Audiologists to the
HIC
Strategies f % Services f %
Educational, medical
referral
Teacher preparation
Collaboration with SLT
Specialised instructions
Counselling
4
2
2
1
6
57.2
28.6
28.6
14.3
85.7
Fitting and dispensing
hearing aids
Auditory training
Compensatory
strategies training
Facilitating transition
between grades
2
4
1
1
28.6
57.2
14.3
14.3
The above table shows the variety of services and strategies used by the
audiologists, for the rehabilitation of HIC studying in special schools of Punjab. It is clear
from the table that counselling is the most common activity practised by the audiologists.
57% audiologists were used to refer the HIC for appropriate educational or medical
intervention while the same percentage was directly involved in providing auditory skill
development training to HIC. 28% audiologists were involved in the fitting of
amplification devices and 28% also reported collaborating with the speech therapist
regarding listening, speech and language development and teacher training. A few of the
audiologists were extending their services to the teachers, in preparation of individualised
plan and helping the individuals during transition between grades or programmes.
202
4.1.5.3 Recommendations of the audiologist
Table 70: Prevailing Situation and the Future Needs as Recommended by the
Audiologists
Areas of Consideration Present Condition Future Needs
• Screening of hearing
impairment.
• Collaboration among
professionals.
• In-service
training facilities.
• Extreme
deficiency of
facilities
• Provisions only in
big cities
• General public is
unaware of the
available provisions
in the hospitals.
• Unreliable
hearing assessment
practices necessary
for success of any
department.
• Courses were
conducted.
• Provision of the
screening facilities
in all basic health units.
• Provision of
calibrated equipment and
material for diagnosis
and assessment of
hearing loss.
• Extreme need of
collaboration
between education,
medical and technical
professionals.
• More courses,
especially for
newly appointed are
demanded.
• Feedback system
after training courses
should be initiated.
203
4.2 PART B
PROPOSED AURAL REHABILITATION MODEL
Data pertaining to the aural rehabilitation model development was mainly
qualitative in nature. The proposed model was finalized after incorporation of the
following:
• All the recommendations of the stakeholders obtained via survey questionnaires.
• Common elements of the already developed models.
• The recommendations of the rehabilitation experts from the field of medical,
educational and directorate of special education.
All recommendations of the stakeholders were coded against the themes related to
educational, audiological cum medical, communication and vocational rehabilitation. The
summarized view of the recommendations of the stakeholders is as follows in figure 7.
Figure 7: Summarized View of the Recommendations of the Stakeholders
204
The graph clearly indicated that all stakeholders strongly recommended the
provision of hearing aids to the HIC. Improvement in the existing educational provisions
for communication skill building and vocational success was highlighted by all
stakeholders. Further improvement in audiological diagnosis and assessment services and
scheduled free medical checkup was also demanded. Professional stress on collaboration
among professionals and multi dimensional treatment approach indicated the need as well
as recommendation for integrated rehabilitation setup.
The description of all already developed models was coded against the five
components of the model as shown with the coding reference count in figure 8.
Figure 8: Coding of the models against five basic components of a model
205
Analysis of the already developed models against five basic components of the
model revealed that there was a varying degree of elaboration of five basic components
of the model and all models explained the output i.e. the nature of services and level of
targets in more detail.
All experts reported positively about the structure of the model after discussion of
the proposed model. However concern was raised about its applicability because of
assumption statement. The proposed CAR model, as shown if figure 9 was finalized after
the inclusion of the following recommendations made by the experts. They recommended
including the following elements:
1. Screening cells
2. home based interventions
3. group therapy approach
4. Mentioning the mental abilities of the targeted beneficiaries
5. Role of carers
6. Elaboration of environmental modifications
7. Adaptive teaching methods &
8. Inclusion of religious component in integrated curriculum development
The diagrammatic representation of the proposed comprehensive aural rehabilitation
model (Figure 9: CAR) along with the theoretical detail of each component of the model
i.e. problem statement, assumption, resources, input, output, outcomes and impact is
given in the following page.
206
Figure 9: CAR Model for HIC in Pakistan
IMPACT
Human / Financial / Organizational
• Parents
• Multi disciplinary team
• Budget for hearing aid and maintenance
• Legislation for mainstreaming HIC
• Hospitals with separate department
• Special education centers
Process / Tools / Actions
• Screening protocol Aural teaching approach
• Curriculum development In-service training
• Need assessment surveys Awareness campaign
• Parental guide/ pamphlet Provision of
Amplification
• Evaluation tool development (Auditory Speech etc)
Pro
ble
m /
Iss
ue
Sta
tem
en
t
ᴥ
Aca
dem
ic,
com
mun
icat
ion a
nd
vo
cati
on
al n
eed
s o
f h
eari
ng i
mp
aire
d c
hil
dre
n a
re n
ot
met
by c
urr
ent
edu
cati
on
sy
stem
of
HIC
in
Pak
ista
n.
Assu
mp
tion
s A
ural teach
ing
app
roach
is successfu
l intern
ationally
as well as in
priv
ate edu
cation
al/clinical settin
gs..
Gov
ernm
ent h
as enou
gh
bu
dg
ets already
allocated
for co
chlear im
plan
t of h
earing
imp
aired ch
ildren
study
ing in
gov
ernm
ent sch
ools in
Pu
njab
. This b
udg
et can b
e div
erted to
ward
s pu
rchase o
f hearin
g aid
and
for
welfare lo
ans.ᴥ
Multi p
rofessio
nals are alread
y w
ork
ing
in sp
ecial edu
cation
centers. Ju
st chan
ge in
aims an
d g
oals
of ed
ucatio
n o
f hearin
g im
paired
child
ren is req
uired
.ᴥ G
ov
ernm
ent h
as signed
edu
cation fo
r all (IDE
A) an
d o
ther
legislatio
n m
ade b
y U
NIC
EF
.
Change in behavior / knowledge / skill level
• Awareness
• Participation
• Attitudes
• Administration
• Technology
• Educational, vocational, auditory and
communication skill building.
Change in Organization / Community System
• Increased efficiency
• Better educational standards
• Improvement in psychological and vocational status
• Increased collaboration in community
• Improved economic status
• Increase in social development
Type / Level / Target of Services
❖ Role of the ministry
• Law formation Budgetary allocation
• Integrated auditory, speech & language Curriculum
• Linguistically appropriate Assessment forms
• In-service training schedule
❖ Role of the principals in the centre
• Pre-school training programme. parent guides
• Awareness campaign. Screening camps
• Maintenance of class room and hearing aids
• Coordination of services in adjacent areas
❖ Role of the teachers
• Development of listening attitude
• Individualized educational planning
• Coordination with mainstream school
• Psychological support and counseling
• Assessment schedule
• Consultation with professionals
❖ Role of the parents
• Hearing protection
• Participation in intervention and Screening programme
• Self assessment report
• Coordination with teachers and therapists
• Coordinate parental training programme
❖ Role of the coordinator
• Provision of relevant information
• Maintenance of progress report of each child
• Coordination at Tehsil/ District level
❖ Role of the audiologist
• Screening, diagnoses and verification of hearing loss
• Provision, modification and maintenance of hearing aidds
• Progressive hearing aid benefits measurement
• Coordination with and training of speech therapist
❖ Role of the speech therapist
• Aural rehabilitation plan
• Environmental modification
• In-service training of teachers ᴥ Consultation
• regarding educational placement and IEP’s
• Progressive assessment and remedial work
• Parental training
• Follow-up of services
❖ Role of the psychologist
• Case histories
• Assessment (cognitive and personal factors, self
• concept, listening attitude, motivation)
• Counseling and stress management
• Behavior modification and adjustment
• Coordination with professionals, parents and peer
group
RESOURCES
rRESOURCE
S
INPUT
OUTPUT
OUTPUT
OUTCOME
OUTCOME
S
IMPACT
OUTCOME
S
207
Following is the detail of each element of CAR along with the problem statement
dealing with and the underlying assumptions of the model.
4.2.1 Assumption and Problem Statement
The proposed model highlighted the main plight of HIC with poor academic,
communication and vocational skill building. The researcher emphasised that the current
educational cum rehabilitative services are not focusing on the main problem
(listening/speaking) of HIC and the whole budget and efforts are targeting the linked
associated areas. Therefore, initiation of integrated aural rehabilitation services, as the
main change in a policy statement about the rehabilitation of the HIC is the utmost need
of the day. The researcher is also hopeful as the base line services and professionals are
already available in the system and just changes in the basic ideas and beliefs about the
rehabilitation of HIC may bring change in the life of HICs.
4.2.2 Resources
Resources (Human, Financial, Community, and Organisation) needed to operate
programme were decided to be as follows:
1. Multidisciplinary team for evaluation and planning.
2. Parents as the primary agent of (re)habilitation after receiving the psychosocial
support and training from other team members.
3. Budgetary allocation for provision of bilateral digital hearing aid and loans to
purchase aids to all HIC studying in special education schools/centres in Punjab.
208
4. All special educational schools/centres have to play active role in hearing protection,
awareness, home based training services, screening, early intervention etc.
5. Laws regarding the compulsory mainstreaming act and welfare loans need to be
formalised.
6. The Ministry/directorate has to coordinate services regarding integrated speech
language curriculum development, development of assessment tools in regional
languages, scheduling in-service training of teachers and professionals, surveys to
check consumer’s satisfaction and to determine future needs regarding parental
training programmes, guidance and counselling pamphlets, research support to
professionals, etc.
7. Hospital support services in separate units for the disabled through separately
allocated doctors to deal with HIC
4.2.3 Inputs
Inputs (processes, tools, techniques, action, events of services) of the planned activities
were decided to be as follows:
1. Region wise screening camps with monitored screening protocols to be controlled by
the directorate of special education.
2. Special education centers to be the hub of all awareness and prevention campaigns.
3. Scheduled need assessment surveys to be the part of all future plans of rehabilitation.
4. Use of acoupedic/aural approach to learning process rather than sign language as
medium of instruction.
209
5. Development of screening and diagnostic batteries covering auditory, speech,
language, lip reading, vocabulary, comprehension, speech intelligibility areas etc.
6. A legally supported provision of hearing aids, Hearing aid orientation training and
tools for monitoring the benefits of hearing aid.
7. Structured and developmental approach to auditory, speech and language skill
development.
8. Counselling and guidance services covering psychological support and personal
adjustment training.
9. Development of home based training programme covering early childhood
educational support, home based educational services, follow-up services, cognitive
and vocational development, etc.
10. In-services training schedules and manuals for teachers, audiologist, psychologist,
therapist, Heads of institutes and coordinator of all these services.
11. Specialized parental training and involvement plans with monitoring by the
committee of parents and professionals.
4.2.4 Output
Outputs (type/level of goals services, targets to be delivered) were decided to be as
follows:
1. Necessary environmental modification for an aural approach to be successful in
schools includes a gradual shift from signs to speech and language in senior classes
and use of auditory oral /verbal approach fully in its true sense in junior classes.
210
Choice of opting the with or without sign language mode of communication for
teaching learning process should be available to the parents of HIC and arrangement
for two different approaches of teaching should be made.
2. Screening protocols i.e. initial screening at hospitals at time of birth, screening camps
at 6 months interval at every Tehsil Head Quarter and special educational centres at
tehsil level in addition to development of checklists for parents for identification of
hearing loss, hearing loss prevention, hearing protection guidance papers and general
awareness about diagnosis and impact of hearing loss in the lives of HIC should be
published and distributed in near vicinity of all special schools and centres.
3. Use of uniform diagnostic and assessment tools including case histories, hearing loss
identification and diagnosis, evaluation of personal factors, culturally and
linguistically appropriate speech, and language and intelligibility assessment in all
special education schools / centres should be monitored at 6 month intervals.
4. Individual aural (Re)habilitation plans covering compulsory amplification of all,
hearing aid maintenance and aid benefit assessment, communication training of
significant others, speech language and auditory skill building with intermediate
necessary modification in AR plan along with informative counselling and follow-up
of services should be prepared by area coordinators and/or audiologist in consultation
with the parents, teachers and speech therapists.
5. Development of curriculum for HIC with overlapping targets for the development of
listening, speech and language, literacy and numeracy skills and vocational skill
211
oriented tasks, separately for each educational level. Integrated curriculum should be
activity based and workbooks having periodical worksheets and assessment sheets (at
regular intervals) should accompany the curriculum. The SLT’s and other
professional are held responsible to monitor the progress of each child and suggest
remedial work to be done.
6. The preschool years are the most critical period in the lives of HIC, as supported by
numerous research results so; special arrangements to intervene in these years should
be intensified, including the regular parental consultation with special education
teachers, SLTs, audiologists, psychologists, etc immediately after diagnosis. A
training programme should be prepared and delivered to the parent which should be
weekly monitored by the team of coordinator, volunteer or SLT’s. Special emphasis
on amplification, parental training, guidance, stress management and development of
listening/speaking attitude should be given to prepare a strong base over which the
future has to stand.
7. All HIC should be taken as a student to be mainstreamed in the near future. Thus
his/her preparation to enter into a normal school should be the main target of
educating the child. The curriculum of the first five years should run parallel to the
demands of mainstream schools. The administrator or coordinator should be held
responsible to choose such a school in the near vicinity and to be in touch with its
administration. The services of the professionals like SLT’s, audiologist,
psychologist, etc. should rotate in the mainstream schools to monitor the progress of
212
each child, twice in a month and at least for two years. Moreover the training and
guidance of normal education teachers regarding class room acoustics, signal to noise
ratio, special educational needs, adaptation in the curriculum to accommodate these
needs, etc. should be the responsibility of special school professionals and
administration. Regular follow-up of all HIC whether studying in normal schools or
special schools should be the core element of all services delivered to them.
4.2.5 Outcomes
Outcomes that are expected to come, as a change in participant’s behaviour, skills,
knowledge and functioning level are likely to be as follows:
1. Attitudinal change in the parents, hearing impaired children, multi-professionals and
in the community as a whole.
2. Development of listening attitude via speech perception skill development and
auditory skill building in HIC.
3. Psychological change in an individual shown as changes in self-concept, acceptance
level, sense of responsibility, adjustment to the surrounding environment, reasonable
expectations and stress management of both child and the parents.
4. Communication skill building via speech, language and listening skill development.
5. Social development in the society in the form of social justice, law information, etc.
6. Vocational skill building of HIC.
7. Better educational standards prevailing in institutes focusing on effectiveness of
teachers for students and community learning as a whole.
213
8. Administrative and cultural change due to change in aims of education and
technological advancement.
9. Increased coordination among multi-professionals working for rehabilitation of HIC.
4.2.6 Impact
Both intended and unintended system/community level changes likely to occur are as
follows:
1. Increased participation of all stakeholders connected directly or indirectly with the
aural rehabilitation process.
2. Creation of empathetic environment and positive concept of disability.
3. Social development having increased national collaboration and commitment.
4. Improved educational standards and vocational skill development.
214
4.3 PART C
URDU SPEECH PERCEPTION TEST
This section deals with the data analysis pertaining to phonetic balance of Urdu
language and establishing reliability and validity of Urdu Speech perception test (USPT).
Mean frequency of occurrence of the Urdu consonants of the three speech samples of
2150 words collectively is given in the table 71 and 72 below.
Table 71: Mean Frequency of Occurrence of Urdu Consonants
Sounds Sample A Sample B Sample C Mean In twenty-five
word list
/p/ 34 41 54 43 1.50
/b/ 37 56 62 52 1.80
/t/ 16 58 58 44 1.53
/d/ 16 14 18 16 0.55
/k/ 95 133 179 135 4.71
/g/ 35 65 48 49 1.71
/f/ 12 39 35 29 1.01
/v/ 89 72 126 96 3.35
/ᴽ/ 3 4 21 9 0.31
/ð/ 35 32 50 39 1.36
/s/ 58 69 94 73 2.54
215
Table 72: Mean Frequency of Occurrence of Urdu Consonants
Sounds Sample A Sample B Sample C Mean In twenty-five
word list
/z/ 6 21 19 15 0.52
/š/ 7 8 36 17 0.59
/ž/ 39 63 32 45 1.57
/h/ 129 105 171 135 4.71
/m/ 74 49 74 67 2.33
/n/ 87 69 100 85 2.96
/ɳ/ 1 3 4 2 0
/č/ 16 20 35 24 0.83
/j/ 27 19 28 25 0.87
/l/ 59 46 62 56 1.95
/r/ 91 137 121 116 4.05
/x/ 5 3 5 4 0
/v/ 7 0 1 3 0
/ṛ/ 7 8 5 7 0.24
The pilot study was conducted to establish reliability and validity of the USPT.
Detail of the speech perception scores obtained by 100 normally hearing and 30 HIC is
given in Appendix N. The frequency distribution of the speech perception raw scores
216
obtained by 100 normally hearing children, their percentile ranks and z scores are
depicted in table no 73 & 74.
Table 73: Frequency distribution of Speech Perception Raw Scores of Normally
Hearing Children with Percentile Ranks and z Scores
Raw scores Frequency of the
score (by the
volunteer)
Frequency of the
score (by the
researcher)
Percentile ranks
Value of array
Standard scores
45 0 1 0.01th 27.4
46 0 0 1. 01th 30.37
47 0 0 1. 01th 33.39
48 0 3 3.03th 36.41
49 3 2 4.04th 39.43
50 1 0 9.09th 42.45
51 1 1 10.10th 45.47
52 4 1 12.12th 48.49
53 6 5 16 16th 51.51
54 1 1 29.29th 54.53
55 4 4 37.37th 57.55
56 7 11 55.55th 60.57
57 5 7 67.67th 63.59
58 9 6 82.82th 66.61
59 5 5 92.92th 69.63
60 4 3 99.99th 72.65
217
Table 74: Frequency distribution of Speech Perception Raw Scores of hearing
impaired children with their Percentile Ranks and z Scores
Raw scores Frequency of scores Percentile ranks Standard scores
0 3 1st 38.30
2 1 3rd 40.10
3 2 16th 41.009
4 1 23rd 41.91
5 2 26th 42.81
6 1 32nd 43.71
7 1 36th 44.61
9 1 39th 46.42
10 1 42nd 47.32
11 4 46th 48.23
12 2 60th 49.13
13 1 64th 50.03
16 2 68th 52.74
17 1 75th 53.64
19 1 78th 55.45
24 2 81 st 59.96
25 1 87th 60.86
29 1 91st 64.47
42 2 94th 76.21
218
4.3.1 Establishment of reliability and validity of USPT
The comparison of the mean scores of normally hearing children and HIC in each
age group is shown with the help of the bar chart below:
Figure 10: Predictive Validity of Urdu Speech Perception Test
This chart is the evidence of the predictive validity of the test and it shows that
scores of HIC in each age group are far below the scores of normally hearing children.
Thus the children predicted to differ in test performance actually did so. Moreover, the
comparison of the scores of children having a profound degree of hearing loss and those
having a severe degree of hearing loss is the evidence of the fact that test performance
improves with improving hearing capabilities of the children.
219
4.3.1.1 Construct Validity
The following line graph showing the mean scores obtained by the normally
hearing children within each age group is plotted to show the construct validity of the
test, i.e. scores of the children in each age group are improving with the increase in the
age of the children.
Figure 11: Construct validity of Urdu Speech Perception Test
220
4.3.1.2 Split half reliability
The scores of the ten children belonging to each age group were randomly
selected. Their scores of even numbered items and odd numbered items were tabulated.
The 0.662 correlation of the two scores was obtained by using the formula.
The correlation coefficient of the total test was calculated by using Spearman’s
Brown prophecy formula i.e. r of the total test = . And the value of 0.798 was
obtained which is quite high.
t-test to check The significance of the relationship at with d.f = n-2, was
administered by using the formula: t = r
The calculated value of t i.e. 3.745 was falling in the critical region
at , thus null hypothesis was rejected and there was enough
evidence to support the claim that there is a significant positive correlation between the
split half scores of the speech perception test.
4.3.1.3 Test-retest Reliability
It was also calculated by taking a retest of the ten randomly selected children after
the interval of 3 months (The gap between tests is appropriate as the differences in speech
perception skills are not likely to occur in three months duration).The value of r was
calculated between test and retest scores of these children by using formula:
221
The correlation between test-retest scores of the ten children was found to be
0.881. t-test was administrated and the correlation between scores was significant
at
level with d.f = n-2.
4.3.1.4 Inter-scorer Reliability
It was also calculated by using scores of same ten children tested by both testers.
Spearman’s formula was used to calculate the correlation.
And the correlation was found to be 0.0598 which was moderate. The significance
of the correlation was checked by applying t-test. It was found to be significant at 0.10
level, but not at 0.05 level. Detail of the randomly selected raw scores of children, used to
determine the reliability of USPT is given in Appendix O.
222
4.4 PART D
EXPERIMENTAL SECTION
Part D deals with the analysis of the experiment done to validate the CAR model for HIC
in Punjab.
The randomly selected children for experimentation were pre-tested and assigned
to two groups (control and experimental groups). Pretest mean and S.D of both were
calculated and shown below:
Table 75: Mean and S.D of Pretest Speech Perception Scores of Control Group and
Experimental Group
GROUP N Mean S.D
Control 12 9.41 8.37
Experimental 12 9.58 4.27
As the above table shows, the mean pretest scores of comparison groups
appeared to be quite similar whereas, S.D appeared to be quite different for both groups.
223
Table 76: Significance of the Difference between Mean Pretest Speech Perception
Scores of Control Group and Experimental Group
t-test
Mean S.D S.E t P
Control group 9.41 8.37 8.460 -0.02 0.984
Experimental group 9.58 4.27
Degree of freedom= n-1=11 Critical value at α 0.05 = ±2.202
Two-tailed t-test was applied and the t value of -0.02 was obtained. This
value is not significant at 0.05 level of significance. The result is not significant at p ˂
0.05. The null hypothesis was not rejected and it was concluded that no significant
difference was present at the pretest level of the comparison groups. Thus the two groups
were homogeneous. After six weeks period of training to only experimental group, both
groups were again re-tested and posttest scores were obtained.
Table 77: Mean and S.D of Posttest Speech Perception Scores of Control Group and
Experimental Group
GROUP N Mean S.D
Control 12 11.58 11.12
Experimental 12 28.33 6.67
As the above table shows, both mean and S.D of posttest scores of the
comparison groups appeared to be quite different from each other.
224
Table 78: Significance of the Difference between Mean Posttest Speech Perception
Scores of Control Group and Experimental Group
Posttest Mean S.D S.E t P
Control group 11.58 11.12 3.718 -4.50
0.0009
Experimental group 28.33 6.67
Degree of freedom= n-1=11 Critical value at α 0.05 = ±2.202
α 0.02 = ±2.718
α 0.01 = ±3.106
Two-tailed t-test was applied and the t value was -4.50. This value is
significant at 0.05 level of significance. The result is significant at p ˂ 0.05 Thus the null
hypothesis was rejected and it was concluded that there was significant difference present
at the posttest level of the comparison groups. And this value was not significant not only
at 0.05 level, but also at 0.02 and 0.01 level of significance.
225
Table 79: Significance of the Difference between Mean Pretest, Posttest Speech
Perception Scores of the Control Group
t-test
Control group Mean S.D S.E t P
Pretest 9.41 8.37 4.81 0.137 0.8935
Posttest 11.58 11.12
Degree of freedom= n-1=11 Critical value at α 0.05 = ±2.202
Two-tailed t-test was applied and the t value was 4.81. This value is not
significant at 0.05 level of significance. The result is not significant at p ˂ 0.05. Thus the
null hypothesis was not rejected and it was concluded that there was no significant
difference present at pre- and posttest level of the control group.
226
Table 80: Significance of the Difference between Mean Pretest, Posttest Speech
Perception Scores of the Experimental Group
t-test
Experimental group Mean S.D S.E t P
Pretest 9.58 4.27 1.32 -14.20 .0000
Posttest 28.33 6.67
Degree of freedom= n-1=11 Critical value at α 0.05 = ±2.202
Two-tailed t-test was applied and the t value was -14.20. This value was
significant at 0.05 level of significance. The result is significant at p ˂ 0.05. Thus the null
hypothesis was rejected and it was concluded that there was significant difference present
at pre- and posttest level of the experimental group. Thus we can conclude safely that
there is significant improvement in the speech perception scores of experiment group at
posttest level, which is definitely the result of the auditory training provided to them, as
significant difference cannot be due to chance. And this value was not significant not
only at 0.05 level, but also at 0.02 and 0.01 level of significance.
227
Table 81: Age wise Mean and S.D of Pretest Speech Perception Scores of the
Control Group and the Experimental Group
Pretest Control Group Experimental Group
Age 5-9 years 10-14 years 5-9 years 10-14 years
Mean 7.16 11.66 10.33 8.83
S.D 8.90 7.91 4.17 4.62
N 6 6 6 6
As the above table shows, the mean and S.D of pretest scores of younger and
older HIC of the comparison groups appeared to be quite similar to each other.
228
Table 82: Significance of the Difference between Mean Pretest Speech Perception
Scores of the Younger and Older HIC of Control Group and Experimental Group
Pretest Mean S.D S.E t P
Control group (5-9 years) 7.16 8.90 4.860 -0.925 0.397
Control group (10-14 years) 11.66 7.91
Experimental group (5-9 years) 10.33 4.17 5.704 0.350 0.740
Experimental group (10-14 years) 8.83 4.62
Degree of freedom= n-1=5 Critical value at α 0.05 = ±2.571
Two-tailed t-test was applied and the t value was -0.925 for the control group
and 0.350 for the experimental group. These values were not significant at 0.05 level of
significance. The results are not significant at p ˂ 0.05. Thus, it was concluded that there
was no significant difference in pretest scores of the younger and older HIC of both
control and experimental group.
229
Table 83: Age wise Mean and S.D of Posttest Speech Perception Scores of Control
Group and Experimental Group
Control Group Experimental Group
Age 5-9 years 10-14 years 5-9 years 10-14 years
Mean 8.66 14.5 29 27.66
S.D 11.41 10.89 8.39 5.16
As the above table shows, the mean and S.D of posttest scores of the younger
and older HIC of comparison groups appeared to be quite similar to each other.
230
Table 84: Significance of the Difference between Mean Posttest Speech Perception
Scores of the Younger and Older HIC of Control Group and Experimental Group
t-test
Posttest Mean S.D S.E t P
Control group (5-9 years) 8.66 11.41 4.860 -0.908 0.405
Control group (10-14 years) 14.5 10.89
Experimental group (5-9 years) 29 8.39 5.704 0.333 0.752
Experimental group (10-14 years) 27.66 5.16
Degree of freedom= n-1=5 Critical value at α 0.05 = ±2.571
Two-tailed t-test was applied and the t value was -0.908 for the control group
and 0.333 for the experimental group. These values were not significant at 0.05 level of
significance. The results are not significant at p ˂ 0.05. Thus, the null hypothesis was not
rejected and it was concluded that there was no significant difference in posttest scores of
the younger and older HIC of both control and experimental group. We can also conclude
safely that age difference did not interfere with the speech perception skill development,
at least during initial phases of development.
231
Table 85: Significance of the Difference between Mean Pre- Posttest Speech
Perception Scores of HIC Boys and Girls of the Control Group
t-test
Control group Mean S.D S.E t P
Pretest boys 5 6.13 17.752 -0.497 0.640
Pretest girls 13.88 8.304
Posttest boys 5.833 5.776 5.680 -1.87 0.120
Posttest girls 16.5 12.66
Degree of freedom= n-1=5 Critical value at α 0.05 = ±2.571
Two-tailed t-test was applied and the t value was -0.497 for pretest boys and
girls of control group and -1.87 for the posttest. These values were not significant at 0.05
level of significance. The results are not significant at p ˂ 0.05. Thus the null hypothesis
was not rejected and it was concluded that there was no significant difference in the
pretest as well as posttest scores of the HIC boys and girls of the control group.
232
Table 86: Significance of the Difference between Mean Pre- Posttest Speech
Perception Scores of the HIC Boys and Girls of the Experimental Group
t-test
Experimental group Mean S.D S.E t P
Pretest boys 8 4-60 2.384 -1.328 0.241
˃0.05 Pretest girls 11.16 3.60
Posttest boys 28.33 7.76 3.733 0 P=1
˃0.05 Posttest girls 28.33 4.84
Degree of freedom= n-1=5 Critical value at α 0.05 = ±2.571
Two-tailed t-test was applied and the t value was-1.328 for the pretest boys
and girls of the experimental group and zero for the posttest. These values were not
significant at 0.05 level of significance. The results are not significant at p ˂ 0.05. Thus
the null hypothesis was not rejected and it was concluded that there was no significant
difference in pretest as well as posttest scores of the HIC boys and girls of the
experimental group. It is again concluded that like age, gender difference also did not
interfere with the speech perception test results before and after the experimental
training. This result has important implication for planning and dispensing the aural
rehabilitation services to the HIC.
233
CHAPTER 5
SUMMARY, FINDINGS, CONCLUSIONS, DISCUSSION
AND RECOMMENDATIONS
5.1 SUMMARY
The study was designed to develop and validate the model of aural
(Re)habilitation for profound HIC in Punjab. The main objectives of the study were, to
critically appraise the available provisions for aural rehabilitation of profound HIC in
Punjab, to develop the model of aural rehabilitation, to construct a standardised tool for
validation of the model and to conduct an experiment for validation of the model. The
design of the study was pretest, posttest control group design. The study was delimited to
HIC studying in government special education schools/centres of Punjab.
Five questionnaires for parents, teachers, SLTs, principals and audiologists were
developed to collect information about current provisions for aural (re)habilitation of HIC
in Punjab. Units of the sample were thirty institutes from which 448 questionnaires were
received back containing detailed information about 1386 HIC. Data analysis was done
mainly by calculating simple percentages.
Logic model development guide was used to decide the structure of the model and
to analyse the already developed model. The proposed model was decided by
incorporating maximum suggestions of stakeholders obtained through five
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questionnaires. The tentative structural composition of the model was discussed with the
experts in the field of rehabilitation and persons responsible for planning of rehabilitation
of HIC. After incorporating all their criticisms, model of aural rehabilitation was
finalised.
An Urdu Speech Perception Test was constructed as a tool for the experimental
validation of the model, after establishing the content validity of the tool. A pilot study
was conducted to establish validity and reliability of the tool. Speech perception scores of
100 normally hearing children and thirty HIC were obtained to get evidence of adequate
predictive and construct validity of the tool. Split half reliability of the USPT was 0.798,
test-retest reliability was 0.881 and inter-scorer reliability was 0.598, which were also
quite reasonable.
As a validation of all structural components of the model was not possible, only
the segment of auditory training was selected for the experimental validation of the
model. For conduction of experiment, one special school of Rawalpindi having maximum
number of profoundly deaf, hearing aid users (bilateral-digital-behind the ear), was
selected. The selected children, fulfilling the criteria of the experiment were pre-tested
and twenty-four paired HIC were assigned randomly to the control group and the
experimental group. After providing six weeks auditory training to twelve children of the
experimental group, posttest scores of both groups were obtained. The mean and standard
deviation were calculated and t-test was used to check the significance of differences in
mean pre and posttest scores.
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5.2 FINDINGS
The main findings of the study are delineated below:
5.2.1 Survey Questionnaires
1. The return rate of the survey questionnaires was 50%. (table 3 & 6)
2. 53% special education teachers were within ages between 26 to 35 years, 83% were
female, 57% were master’s degree holders and 60% were employed as senior teachers
having experience of 1-8 years. (table 7,8 & 9 )
3. The data of 886 HIC, contained in the teachers’ questionnaires revealed that 31%
were 4-12 years old and 36% were 13-21 years old. 55% of HIC were with severe and
profound degree of deafness. (table 10)
4. 78% HIC were not provided with the hearing aid. Out of 19% HIC having aid 52%
were not regular users and 56% were not comfortable while using their aid. (table 11
& 12)
5. 63% HIC did not have access to speech therapy services and 32% were using only
sign language as a mode of communication. Whereas 21% HIC had speech
development of word level.(table 13)
6. 56% HIC were skilful in sign language and 51% teachers were able enough to
communicate through sign language. 90% teachers were using total communication
as a mode of communication while teaching. (table 14 & 16)
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7. A significant finding of the study was that 60% and 32% HIC were able to
comprehend the subject matter fully and partially respectively if taught with the
speech only mode of communication, as perceived by their teachers. (table 15)
8. 34% teachers of HIC recommended total communication while 22% voted for aural
approach as a mode of communication while teaching. 26% teachers recommended
provision of hearing aid and 30% recommended vocational training for HIC. At least
30% teachers gave no recommendations about HIC. (table 17)
9. It was found from responses obtained from questionnaires of parents of HIC that 29%
children were in preschool, 25% were in primary and 27% were in high classes. 59%
HIC were girls and 40% were boys. (table 18)
10. 62% HIC had the same disability in their families with 24% having H. I brothers and
22% having H. I sisters. (table 19)
11. Only 17% fathers and 7% mothers had an educational level of bachelors or above.
49% mothers were housewives and 31% fathers belonged to lower level skilled
profession, 40% families had four-five children with 52% having Rs. 10,000 -15000
monthly income. (table 20, 21 & 22)
12. 68% HIC had hearing loss present at birth and Punjabi was the main language of 47%
HIC’s families. (table 23 & 24)
13. According to the parents, 30% HIC had a good communication level with their father,
34% had very good communication with their mothers, 32% had a good
communication level with brother, 29% had very good communication level with
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sister, 36% had very good communication level with teacher and 30% had average
communication level with others. (table 28, 29 & 30)
14. For the last six months, 35% parents had availability of teachers, only 15% parents
had availability of psychologist, 17% of SLT’s and 15% had the services of
audiologists. (table 31)
15. 52% parents wished for contact with different professionals, 16% parents demanded
audiologist and 14% parents demanded the availability of speech therapist in
schools.(table 32)
16. 17% parents reported very much support available from child specialist, 15% reported
very less support from an ENT specialist, 22% reported very less support from
teachers, 15% reported very much support from psychologist 18% reported very less
from audiologist, 15% reported very less support from the speech therapist, 11%
reported very much from family and 12% reported very much support available from
the social case worker. 44-71% parents did not comment on the availability of these
professionals. (table 33, 34, 35, 36 & 37)
17. 25% parents wished the availability of different professional at the time of diagnosis
while 38% did not wish. Out of those demanding parents, 40% parents wished the
availability of SLT’s and 35% wished for audiologist at the time of diagnosis while
58% did not mention the specific professional they wished for. (table 38)
18. During primary school years, 13% parents reported very much support available from
paediatricians, 13% reported very less support from ENT, 34% reported very less
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from teachers, 13% reported very less from psychologists. 19% reported very less
from audiologists, 16% reported very less from SLT’s, 11% reported very less from
family and 13% reported very less support available from the social case worker.
(table 39, 40, 41, 42, & 43)
19. 33% parents wished to have availability of support from different professionals
during primary school years and 30% did not wish so. Out of the parents having the
wish, 30% parents wished the availability of the SLTs and 27% wished for the
audiologist during primary school years. 30% parents did not mention the desired
specific professional services. (table 44)
20. 88% HIC were continually passing through the different grades. 21% parents
complained that their children’s special needs were neglected by the hospitals and
schools. While 75% parents gave no response to this important item of the
questionnaire. (table 38 & 44)
21. Only 23% parents attempted to answer the open-ended questions of the questionnaire.
The majority of the parents reported lack of money to purchase the aids and services
of aural rehabilitation. Most of them reported the lack of facilities in institutions and
support from professionals. Parents linked these deficiencies, as the inefficiency of
the education department. Many of the parents were satisfied by the education system
to some extent, but the same percentage reported the lack of support from hospitals.
Most of the parents of older HIC pointed out the scarce employment opportunities
and the lack of skill oriented curriculum and training facilities. (table 45)
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22. The majority of the parents recommended the provision of hearing aid, financial
support for maintenance of aid and medical intervention by the government. They
suggested the allocation of separate departments and doctors for special people in all
hospitals and free regular/monthly checkup of the HIC. Most of the parents demanded
extensive speech and auditory development facilities, enhancement of transportation
facilities, re-provision of milk and strengthening of the staff of all special education
institutions. Parents also recommended curriculum changes like more focus on moral
values, speech and language development and vocational training with job placement
or internship facilities. (table 46)
23. 66% SLT’s were 26-30 years old having a master’s degree. 83% of SLT’s were
appointed on a regular basis, having 1-3 years’ experience. (table 47 & 48)
24. 62% HIC, receiving therapy, were in grades from preschool to class 2 and 58% HIC
were receiving only 1-2 therapy sessions per week. (table 49)
25. 61% HIC selected by SLT for therapy were having hearing aids whereas, 86%
hearing aid users were not regularly using their aid as 83% were not comfortable with
their aids. (table 50)
26. Speech therapists reported that 54% of HIC were able to detect environmental
sounds, 60% could detect speech sounds and 63% were able to localise sound.
Whereas 56% HIC were not able to monitor the output of their amplification devices,
97% could not detect the source of music, 46% couldn’t discriminate between loud
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and soft sound and 97% couldn’t discriminate between the voices of two different
persons. (table 51)
27. As far as listening skill was concerned, it was found that 47% HIC were not able to
identify their names or the name of colours or body parts. Moreover, 53% HIC were
able to comprehend the connected speech of 1-2 words only and 47% were able to
identify stop sounds and 44% could identify nasals. (table 52)
28. 83% SLTs were provided with material needed for intervention, 66% were having a
speech therapy room equipped with appropriate furniture, 50% were provided with
material and equipment needed for assessment and diagnosis of hearing loss and the
same percentage was provided with HATs to be used with HIC. 33% SLTs were
availing the provision of recording equipments like C.D. Player and sound treated test
booth. (table 55)
29. 83% SLTs were taking case histories and detailed speech and language assessment of
HIC. 50% SLTs were updating their assessment annually and 50% were updating bi-
annually. 50%. The SLTs were keeping a record of all current speech therapy targets
whereas 33% were having a record of previous targets also. Only 33% SLTs were
taking detailed auditory skill assessment of HIC and have completed record of each
child. (table 53 & 54)
30. Only 16% SLTs reported satisfactory communication and collaboration with parents,
teachers, support from administration, teacher training and auditory training facilities
and provision of hearing aid to HIC. 33% SLTs reported very less collaboration,
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support and training facilities and 67% SLTs reported very less available provisions
for hearing aid. 83% SLTs recommended an increased level of all provisions, support
and facilities. 50% SLTs reported to have an excessive workload and 33% demanded
the provision of another SLT in institutions in near future. (table 56)
31. 50% principals were 46-50 years old. 71% principals were female and with a master’s
degree. All principals were appointed on a permanent basis and 85% were employed
on the same post, 28% were having either 1-5 years experience or 21-25 years
experience. (table 57 & 58)
32. All special schools were providing teaching of basic subjects like languages,
numeracy, General Knowledge/Science. All special institutions run by Punjab
government were providing free books, transportations, uniform and scholarship to
students. The total number of the teachers in schools varies with the highest
percentage of teachers in special institution for the hearing impaired and lowest in
special education centres, catering all four disabilities, having in average 2-3 teachers
for 60-80 HIC, studying in different grades. (table 59)
33. Drawing, tailoring and computer education were taught in 90% special education
institutions as vocational subjects whereas, provision of vocational teachers and
sewing machines was only 64%. 42% institutions had computer laboratories and 35%
had separate art room. (table 60)
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34. Listening, speaking, reading, and writing skills were reported to be the goals of
educating HIC, but it was found that the available provisions for any targeted area
were from 21% to 50% only. (table 61)
35. A variety of co-curriculum activities were available to HIC with 100% facility of
transportation and 85% had sports ground. Only 35% institutions were having
physical education instructors. (table 62)
36. Maximum institutions were providing support in the form of guidance and
counselling services, whereas the existence of available provisions within different
institutions varies a lot. For medical intervention, all institutions were referring HIC
to the hospitals and for psychological intervention 42% institutions were providing
services of the psychologist and social case worker. (table 63)
37. All the institution’s reported to have specially trained staff and in-service training
facilities, but facilities for parallel training regarding mainstreaming of HIC and
provisions of different facilities to the professionals were scarce. (table 64)
38. 85% questionnaires of audiologist were filled by some senior teachers, performing
duties of an audiologist in their institutions. 71% were male permanent employees
and 42% were having 1-3 years experience. (table 65 & 66)
39. 42% audiologists were provided with sound treated test booth, clinical audiometer
and computers. (table 67)
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40. All audiologists were doing pure tone audiometry and 71% were taking case histories,
mainly at the time of admission. Only 28% were updating the auditory assessment.
(table 68)
41. 85% audiologists were providing guidance and counselling services, 57% were
involved in auditory training and medical or educational referral. Training of
teachers, SLTs and fitting and dispensing aid was practised by only 28% audiologist.
(table 69)
42. All audiologist reported satisfactory conditions regarding in-service training
programmes and recommended to initiate a feedback system after the courses, in
addition to more courses for freshly appointed employees. All of them reported the
extreme need of collaboration among different professionals. (table 70)
43. All audiologists reported extreme deficiency of screening facilities and lack of
awareness about the existing facilities (currently available in big cities only). They
recommended to start screening at all basic health units and provision of calibrated
equipment and materials for auditory assessment and diagnosis of the hearing loss.
(table 70)
5.2.2 CAR Model
44. Basic logic model components were resources, inputs, output, outcomes and CAR
model gave a detailed account of all five basic components in addition to the problem
statement and assumption of the model. It has all common components of
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contemporary models and it incorporated all the recommendations made by teachers,
parents, administrators, SLT’s and audiologists. (figure 7)
45. Screening protocol, aural teaching approach, integrated aural, speech and language
curriculum development, provision of amplification devices, awareness cum
prevention campaigns, annual need assessment surveys and tool development in
regional languages were the main inputs of the model.
46. The model has separately outlined the role of each stakeholder involved in the
process of rehabilitation. The comprehensive detail of the type and level of services to
be provided, was delineated as the output of the model.
5.2.3 Urdu Speech Perception Test
47. It was found that Urdu Speech Perception Test (covering detection, discrimination,
identification and comprehension level of speech perception skills) has established
content validity by professionals. The phonetic balance of spoken Urdu language was
present in the list of twenty-five words selected for the task of identification.
(Appendix I & J, table 5)
48. Speech perception scores of the children of the pilot study gave evidence of
predictive and construct validity of the test. (figure 8 & 9)
49. It was found that the split half reliability was 0.668 (between the half scores of USPT)
and of full test was 0.798 which was significant at 0.05 level of significance (degree
of freedom n-2). The value was significant also at 0.02 and 0.01 level of significance.
(Appendix N)
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50. It was found that the test, retest reliability of USPT was 0.881 which was again
significant even at 0.01 level of significance. (Appendix N)
51. It was found that inter-scorer reliability was 0.598 which was significant at 0.10 level
of significance, but not at 0.05 level of significance. (Appendix N)
5.2.4 Experimental Validation
52. There was no significant difference present at the pretest level of the comparison
groups at α=.05 thus was not rejected. (Table 76)
53. There was significant difference present at the posttest level of the comparison
groups, at 0.05 level of significance thus was rejected. The difference was
significant even at 0.01 level of significance. (table 78)
54. There was no significant difference present at the pre and posttest level of the control
group, at 0.05 level of significance thus was not rejected. (table 79)
55. There was significant difference present at the pre and posttest level of the
experimental group, at 0.05 level of significance thus was rejected. The value of
t was also significant at 0.01 level of significance. (table 80)
56. There was no significant difference present between mean pretest scores as well as
mean posttest scores of older and younger HIC of control group as well as older and
younger HIC of experimental group at 0.05 level of significance. (table 82 & 84)
57. There was no significant difference present between the mean scores of pretest boys
and girls as well as between the scores of posttest boys and girls of the control group
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at 0.05 level of significance. The results of boys and girls of the experimental group
were also same both at the pre and posttest level.(table 85 & 86)
5.3 DISCUSSION
A study by Naeimeh et. al. (2009) emphasised a conclusion that key to
intervention with deaf children is to establish a communication system for the child and
the parents. Aural rehabilitation is feasible and effective in enhancing activity and
participation for the hearing impaired in developing country. This study emphasised that
the oral communication development of severe to profound HIC in Iran is achievable, but
needs integrated public services in aural rehabilitation and speech therapy. The same kind
of integration was reported to be a necessity in CAR model for HIC in Punjab. Similarly,
Reilly & Khanh (2004) quoted the need of development of an affordable and culturally
acceptable model in Vietnam. Initially, the teacher centred model was propagated, but the
results of the evaluation of specialised schools in Vietnam were consistent with the
research emphasising the involvement of family in rehabilitation. Mauk, White,
Mortensen & Behrens (1991) also reported that parental involvement in addition to child
health and mental status were important factors affecting the outcomes of aural
rehabilitation.
The researcher’s emphasis on screening to be initiated by special schools is in
agreement with Sininger, Grimes & Christensen (2010) who analysed the factors
influencing auditory based communication outcomes in children with hearing loss and
reported that degree of hearing loss, intensity of oral education and even use of cochlear
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implant were not having such an impact on communication skills as at which age the aid
was fitted. It was further added that delay of every month in the fitting of aid would delay
the desired outcome by approximately ¾ of a month. Similarly, Lertsukprasert,
Kasemkosin, Cheewareungroj & Kasemsuwan (2010) evaluated the listening and
speaking skills of twenty-seven profound deaf children who attended the preschool AR
programme and concluded that irrespective of the age of enrollment in programme,
listening experiences alone has a positive relationship with length of speech and
vocabulary development. Mauk, White, Mortensen, & Behrens (1991) also reported some
correlation between starting age of training and the number of days required recognising
sound, but it did not affect the word acquisition. The researcher’s conclusion that
irrespective of degree of hearing loss, age or gender differences all HIC should be
provided with bilateral digital hearing aids supports his conclusion that no relationship
between above mentioned factors and degree of hearing loss existed.
Preference given to provision of bilateral B.T.E. digital learning aid by the
researcher has further supported the research by Bell, Creeke & Lutman (2010) that
modern hearing aids employ sophisticated mechanisms that attempt to separate speech
signals from background noise, subsequently allowing both, with the goals of facilitating
speech understanding by improving S/N ratio. Researcher’s emphasis on maintenance of
S/N ratio by audiologist again supported the results that sensory neural HIC require a
greater signal to noise ratio to achieve speech understanding similar to other persons.
(Hawkins and Yacullo, 1984; Killion, 1997;) A one-decibel improvement in S/N ratio
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corresponds to a six to twelve percent point improvement in speech intelligibility in
background noise (Christensen, 2000; Dillon, 2001).
Great emphasis on auditory training and integrated curriculum in addition to all
other outcomes of CAR model are consistent with the conclusion by May Mederake B.
(2012) that early identification of hearing impairment and early educational intervention
proved not to be sufficient for optimising spoken language development of profoundly
deaf children unless it leads to early amplification and early speech perception skill
development training.
An important finding of the study that the incidence of hearing impairment in
families is increasing and resulting in an overall increase in the population of HIC, is
consistent with results of Barnett, S. (2002) that people with hearing loss constitute
approximately 9% of the US population and the prevalence is increasing. Again the
percentages of deaf parents (3.8% fathers and 3.2% mothers) reported in the current
research are very close to Mitchell & Karchmer (2004) estimate of 5% HIC having at
least one deaf parent in USA. Moreover, the result of the survey that the number of HIC
in special education centres was the maximum as compared to mental retardation, visual
impairment and physically handicapped children is consistent with the 2010 audit report
of the programme and services for students with disabilities in San Francisco i.e.
maximum percentage is of deaf students (48.4%). Fortnum, Davis, Summerfield,
Marshall, Davis, Bamford & Hind (2001) reported the incidence of permanent congenital
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hearing loss in U.K that the prevalence increases until the age of nine years and 50-90%
more children are diagnosed with permanent congenital hearing loss than before.
If we go into detail of the degree of hearing loss, the results of the current
research are in line with the results of Rout & Singh (2010). He reported that 89%
children, diagnosed with hearing loss had severe to a profound degree of sensory neural
hearing loss. Evaluation of special schools in Vietnam gave evidence that severe and
profound deaf comprised more than 60% of programme participants (Reilly & Khanh
2004). A parental survey in New Zealand revealed that profound and severe HIC were
54% and 40% respectively (McKee & Smith 2003). The researcher reported it as 55%
with no information about 36% HIC.
Another important related reference is a summary of literature on global hearing
impairment current status and priorities for action which reported that at least 278 million
are affected from whom 2/3rd live in developing countries (Tucci, Merson & Wilson
2010). Another finding that 50% hearing loss can be prevented in developing countries
by focusing on prevention, early detection and rehabilitation programmes that are
severely limited seems to be supported by researcher’s findings about scarce
rehabilitation provisions in schools and hospitals.
The findings of income per month in India are near to the researcher’s findings,
which reported that 93% deaf families were having less than 102$ per month, whereas
26% parents of the current research reported having monthly income up to 99$ and 26%
were having up to 148$ (Rout, N. et. al. 2008).
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A study of Greater and Lounsbury (1966) showed that about half of the children’s
hearing aids were in poor working condition, and after 27 years, a study by Schow et al.
(1993) found the same working condition of aid and concluded that without careful
monitoring many children will not benefit from their aids. The situation is same here as
depicted by the finding that most of the children were not comfortable when using their
aid and the consequences were evident from the auditory profiles of HIC, where the
majority was at the level of detection of sound and discrimination to some extent only.
The finding that 52% HIC were not using their aid is also in agreement with the statement
by Kochkin (2009); Kochkin (2007) & Southhall et al. (2010) that the stigma associated
with using a hearing aid is a barrier to use aid. Polts and Greenwood in Hearing Review
(2012) by Kristine French and Faith Loven reported that school age children’s
instruments often malfunction. They pointed out the same results that if a child is to
realise maximum auditory potential, amplification must provide reliable auditory input.
Parental comments about the special education system for HIC are in agreement
with the views of the stakeholders in Washington that the education system for deaf is
fragmented and inadequate. And parental suggestions are also similar to parents of HIC
in Washington i.e. strengthening early intervention equipments, expanding resources for
technology based supports, authority for coordination and improving teaching standards
(McKee & Smith, 2006). Parental worries about HICs’ poor academic and vocational
skill building are in line with the findings by Blair, et al (1985) that HIC were falling
behind in schools in 1980’s as much as they were in 1960s and a conclusion made that
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the situation is not likely to change in most schools unless there is an excellent AR, are
strongly supported by the researcher’s conclusion.
Parental demands, as revealed through questionnaires are consistent with the
scope of ethics of the American Academy of Audiology (AAA) 2013 that an audiologist
is an integral part of a team of a school system that manages HIC. Monjot (2012)
reported the parental suggestions that professionals should offer the realistic hope to
parents and services should be immediate and family centred and are supported by the
researcher’s conclusion.
Another main outcome of the CAR model, i.e. development of integrated
listening, speech and language curriculum having repetition of overlapping academic
targets corresponds with Hall, Culatta & Black (2007) conclusions that such a curriculum
design allows goals and objectives to directly relate to assisting the HIC. Structural
composition of CAR model supported Hillsboro who reported CAST (contrast For
Auditory and Speech Training) as a speech text that supports the instructional best
practice, using a multidisciplinary team approach to develop spoken communication
skills regardless of the type and degree of hearing loss or the educational philosophy. He
appraised AUS plan (Auditory Speech Language) as a manual helping the professionals
in developing plans, in separate yet connected areas of auditory, speech and language
development and CAR is also supposed to support these development plans.
Researcher’s emphasis on auditory training to be the part of the curriculum for
HIC are in line with the conclusion made by Moore and Amitay (2007) who remarked
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that auditory training has the potential to revolutionise professional practices in
audiology, SLP, classroom teaching and other professions. The steps of experimental
training are consistent with the rules of auditory training, including both top-down
cognitive processing and bottom-up sensory processing also recommended by Murray
(2000).
The resultant significant difference in mean posttest scores of comparison groups
of this study just after 4 weeks training supports the findings of Moore and Amitay
(2007). They quoted the dramatic learning in just one to two presentations of a simple
discrimination task. Auditory skill area wise posttest scores of HIC are evidence of the
equivalent findings by the researcher.
Outcomes of the CAR model like involvement of all the stakeholders in the aural
rehabilitation process, home based training accompanied with immediate feedback and
active collaboration of knowledgeable professionals, etc. are consistent with Tye
Murrey’s model of hearing related disability. Researcher’s model giving stress on the
involvement of parents in AR planning as well as in execution of the plan supports the
Moeller’s conclusion (2000) that out of four factors under study, family involvement
explained the most variance in the language score of five years old HIC. Anjum Bano
(2008) also emphasised in parallel to the researchers’ conclusions that the involvement of
a multidimensional team for assessment, tools of assessment to become an integral part of
the curriculum, provision of enriched auditory environment and individual therapy
approaches to HIC are necessary for auditory skill development.
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The findings about current audiology practices in schools are consistent with the
findings of Schow et. al. (1993) that only 15.6% of the audiologist, they surveyed provide
auditory training. The findings are also consistent with the evidence given by Jennings,
2005, Southhall et al. 2010; Sweetow and Palmer, 2005 that typical audiologic
consultation does not extend beyond hearing aid fitting and orientation. The finding that
other professionals are performing the duties of audiologists in school is in consistency
with the study by Sarah and Thomas (2013) that technicians, nurses, and other health care
providers provide hearing services to people in developing countries. Both of the
researchers reported that only 33% HIC were availing SLTs’ services. Although the
findings of communication level of HIC (word level) appear to be different from the
researcher’s finding i.e. 6% as compared to 21%, but this percentage is likely to change if
the researcher personally would have taken the clinical observations of the children.
The observed, varied SLTs’ practices support the survey results of F. L. that
individual case load and years of practice of SLP affects the intervention decision of
SLPs. The survey results are consistent with Barkimer (2009) survey of SLTs working in
schools who reported lack of parental involvement, high case load, lack of support from
administration and staff and limited resources. These results are also in agreement with
the survey of SLPs of Ohio working in school setting, by Jolly (2009) showing that
curriculum, collaboration and evidence based practice are considered as hindrances in
practising, according to their values.
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SLTs’ demand for more support from the administrator reflects the point of views
of Stokowski and Zagaiski (2003) that when administrators understand the goals of the
team, they are more likely to give the SLP and their team more support in reaching their
goals.
Kristine French and Faith Loven (2000) reported that 69% SLPs felt that their
course work and clinical practicum were inadequate in the area of hearing instruments.
These SLPs recommendations are consistent with the results of current research, i.e. 81%
SLTs considered the in-service training as a necessary requirement. Professionals’
recommendations to increase collaboration with other team members are consistent with
the results of Stokowski and Zagaiski (2003) that ranked collaboration of team members
as a vital contributor to the success. They further added that successful literacy team
consists of special education teachers, SLPs, literacy coach, parents, social workers,
principals and trained volunteers.
The experimental treatment targets and pattern of the present research are in
consistency with the SPICE auditory training curriculum, emphasising 15 minutes
practice per day on skills from discrete tasks such as discrimination and identifying
words to more global skills focusing on connected speech (Moog, Biedensteins).
Tool development in regional languages and all the effort to develop and validate
the USPT are in line with Medell J.R (2008) conclusion that speech testing material
needs to be linguistically appropriate for the person being tested. Researcher’s
affirmation that speech perception testing can be done in ordinary room is in accordance
255
with Hines (2008) who emphasised the need for speech testing in the presence of
background noise, as well as the need of a rehabilitation plan beyond the hearing aid
fitting.
The content pattern of Urdu speech perception is also in line with SPICE auditory
training curriculum. The first section of USPT and SPICE is detection, then comes supra-
segmental section (differentiate speech sounds according to duration and/or stress
pattern) which is first the segment of the discrimination task in USPT. The next section of
vowel and consonant perception to differentiate among stimuli having same duration,
stress and information but differ only in vowel and consonant is included as half of the
first part of discrimination and full second part of discrimination in USPT. Only the word
segment of USPT is different from SPICE. Then both have connected speech section in
the last.
The criteria for development of USPT i.e. phonetic balance, syllable structure,
range of difficulty in lists and the familiarity of the words is consistent with the speech
perception tests in English, German, Danish, Swedish, Hebrew, Italian, French, Finnish,
Portuguese, etc. Kinsey (2010) in psychometric review of language tests for preschool
children reported that a test is considered as a norm referenced if it describes the detail of
normative samples, test norms showing mean and standard deviation and derived scores
like standard scores, percentile ranks etc., in addition to establishing its validity and
reliability. USPT is in line with the criteria delineated by Kinsey (2010) and thus
considered as a standardised norm referenced test.
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Although the return rate of the survey questionnaires was 50% which initially
seems to be quite deficient to generalise the results to the population, but the return rate
was better than 31% return rate of the survey of parents of high and very high need deaf
students in mainstream schools of New Zealand as reported by McKee & Smith (2003).
The return rate was also better than 27.6% return rate of the 2000 survey of AR Dallin
Millington explained by Boswell (2000) in redefining audiologic rehabilitation. The
results of the current study are consistent with the survey of 1000 ASHA certified
audiologists that major rehabilitation services provided by audiologists merely focused on
instrumentation. The researcher expects that future research results would be similar to
the remaining findings of the 2000 survey of AR Dallin Millington i.e. new approaches of
AR are emerging because aural rehabilitation is becoming a hot debate and interest in the
field is increasing. A study in Nigeria to determine the effectiveness of aural
rehabilitation in developing countries reported the same result that aural rehabilitation is
feasible and effective in enhancing activity and participation for HIC in developing
countries (Olusanya B, 2004).
Although the return rate was just average, but room for improvement is always
there, especially a survey of stakeholders’ recommendations which are likely to become
part of future strategic plan, is liable to have a better response rate. The better response
rate about current provisions for aural rehabilitation and stakeholders’ recommendations
would have brought changes in the CAR model. As only 23% parents attempted the
open-ended questions, so inclusion of closed choice items in questionnaires would have
257
been more helpful to the researcher in getting better responses not only from parents but
also from other stakeholders.
The misconception by parents regarding oral versus manual communication was
noted by the researcher during data analysis which was not evident before through pilot
testing. The problem occurred due to ambiguity in the questionnaire faced by illiterate
parents surveyed, and not by the majority of graduate parents of pilot testing. Another
omission made by the researcher was that while reprinting the questionnaires, an items
were deleted due to some computer trouble shooting. Thus a few parents did not receive
the same questionnaire. A careful observation of all the questionnaires before sending
and saving a master copy for future photocopies might have helped the researcher to
include analysis of all items of the questionnaires in data analysis.
Twelve speech therapists’ questionnaires were received back out of which four
were from the Sir Syed School and College for Deaf. Similarly, only one audiologist was
an audiologist by profession while other questionnaires were filled by the senior teachers,
thus the received questionnaires of these professionals did not represent the diversity of
the population of these professionals.
It was very difficult to get a response from the principals, thus a telephonic probe was
done later on. If the same practice would have been done with the directors of the
Ministry and Directorate of Special Education, Punjab, the opinion over CAR model
would have been more comprehensive.
258
In the development of USPT, only consonantal analysis was done and vowel analysis was
omitted. The whole speech sample analysis is sure to change the phonetic balance
reported by the researcher.
The request of a research grant was declined both by the minister and the HEC and no
sponsorship was available for hearing aids, thus experiment was conducted with small
groups of HIC due to shortage of profound HIC owning digital hearing aids. The
experiment involving a larger number of HIC for a longer duration than 4-weeks would
have helped in getting more reliable results.
5.4 CONCLUSIONS
Following conclusions were drawn on the basis of above mentioned findings:
1. Most of the teachers, SLTs and principal working in special education centres were
young females, holding master degree and appointed on grade 17 on a permanent
basis and having 1-5 years experience. But the majority of the parents of HIC were
poor, not well qualified and belonged to lower skill level occupation or government
job. The quality of different professionals’ services available to the parents either at
the time of diagnosis, or during primary school years or in the last six months was not
satisfactory. Therefore, the majority of the parents wished to have availability of
different professionals’ services. The mostly demanded professionals were the
audiologists and SLTs.
2. Data of the HIC studying in special schools, obtained through teachers’ and parents’
questionnaires showed the diversity of all age groups. Hearing impairment, mainly of
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severe and profound degree was mostly present since birth. The incidence of another
person in hearing impairment families of HIC was quite high and their population
was increasing rapidly. Moreover, the ratio of hearing disabled children was highest
when compared with number of PHC, VIC and intellectually challenged children in
the centres at tehsil level.
3. Most of the HIC studying in schools/centres were not provided with hearing aids and
out of those having aids, the majority were not comfortable with their aids and were
not using them regularly. It was revealed from the auditory profile of the majority of
HIC that they were not getting benefits from their aid as they were able to detect
sounds and discriminate sounds to some extent only. Most of the HIC were not
having a speech therapy session in schools and out of those availing the services,
mostly were having only 1-2 sessions per week.
4. Total communication was the main mode of communication adopted by the teachers
of HIC and the majority of teachers and HIC were skilful in the use of sign language.
However, most of HIC were able to understand the subject matter, taught either with
only speech or with only signs. No great difference was reported in comprehending
the details of the topic. Although the majority of teachers recommended using total
communication, but the difference with other teachers recommending aural approach
was only 12%, making them the second majority. Thus, it was concluded that aural
approach was gaining popularity among teachers.
260
5. Most of the parents as well as professionals reported the lack of educational,
audiological, speech and language development and vocational training facilities in
special education institutes of Punjab. Both audiologists and SLTs reported very low
level of collaboration, communication among professionals, parental involvement and
support from administration and recommended raising these levels. Provisions of
different equipments, materials, and facilities required for assessment and
intervention of HIC were not satisfactory in special schools. The professional
practices of speech therapists were merely covering speech and language skill
building. Least efforts were devoted towards aural skill assessment and development
and updating the record of assessment and therapy. Audiological practices in schools
were restricted to hearing assessment and providing guidance and counselling to
parents.
6. The majority of parents recommended free medical checkup and job placement
services. They demanded a quantitative increase in all the facilities already present in
the institution and curriculum changes focusing on mainstreaming aspects. The
majority of parents as well as different professionals emphasised upon the provision
of the hearing aid to HIC and curriculum development, focusing on listening skills,
speech and language skill development and vocational skill building.
7. The factors like provision of specially trained teachers, books, uniform, transport,
scholarship, co-curricular activities, teaching of a variety of academic and vocational
subjects, guidance and counselling of parents and in-service training facilities were
261
contributing positively towards aural rehabilitation of HIC. But lack of the teachers
and different facilities, especially in all centres at tehsil level, lack of attention
towards auditory, speech and language development, lack of vocational training
facilities and skill oriented education and lack of financial support for hearing aids
were pointed out by all stakeholders, involved in rehabilitation of HIC as the main
hindrances in the rehabilitation process. The least available professional in special
schools was the audiologist. All the stakeholders demanded their availability because
currently audiology services were provided by senior teachers, speech therapists or
nursing assistants in special schools. There was an extreme deficiency of screening
facilities in hospitals and in schools. All the stakeholders recommended starting free
screening camps at all basic health units.
8. As there was no significant difference between the mean pretest scores of the control
and experimental groups, thus both groups were homogeneous before the experiment.
The speech perception ability of the HIC virtually improved as a result of auditory
training provided to them. Neither age nor gender appeared to have any effect on
speech perception skill development, at least in the initial stages of training.
9. The model incorporated all the suggestions and recommendations of all stakeholders
involved in the rehabilitation process, except the HIC’s point of view. The proposed
model was comprehensive, covering the general as well as specific and interrelated
services of AR emphasising multidisciplinary approach and aural approach of
teaching HIC. Urdu Speech Perception Test was a norm referenced reliable and
262
validate tool to assess analytic as well as synthetic auditory skill areas of HIC in Urdu
language. Both USPT and CAR model can help in the planning process and
delivering aural rehabilitation services to HIC.
5.5 RECOMMENDATIONS
The following recommendations are drawn from the above conclusions.
5.5.1 Recommendations for Action
1. The research has brought forward the situation that more than 90% population of the
HIC is profound or severely profound deaf, using sign language as mode of learning
and communication. The progress regarding speech and language development and
auditory skill development is negligible, that’s why a negligible number of HIC has
been mainstreamed. If the government and policy makers really want to achieve the
purpose of education cum aural rehabilitation of HIC, surety of the provision of
hearing aid and curriculum changes covering auditory skill building, speech and
language development is required. All the HIC irrespective of their ages, gender or
hearing loss may be considered as a candidate of hearing aid user and a child to be
mainstreamed within 3-5 years of education. Auditory skill development training is
basic education cum rehabilitation need of every HIC. Moreover, no audition is a
threat to the lives of HIC. Provision of the hearing aid may be given priority, even if
at the expense of free uniform, scholarship, or free books because the poorest parents
can afford these cheap items but can’t think of even updating audiological assessment
privately. Buying and maintaining amplification devices is possible in their dreams
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only. It’s like a joke that if a child got admission in any normal education, public
school of Punjab, chances of getting hearing aid are far brighter than getting financial
support for aid when admitted in any special school/centre.
2. Directorate of Special Education, Punjab has initiated a programme to provide
cochlear implant to profound HIC, but can all the profound HIC, who are almost three
quarter of the total strength of HIC, be provided so? In my view, provision of hearing
aid would be more feasible as the cost of one implant is equal to the cost of
approximately thirty pairs of digital hearing aid of latest technology. Therefore, it is
recommended that the planners of the directorate may reconsider the choice of
hearing aid versus cochlear implant if budget is very limited. The Directorate of
Special Education, Punjab may also reconsider the logic of spending more and more
on the buildings than on the students sitting in these buildings, especially when the
basic purpose of educating those students is not being achieved due to absence of
budgetary allocation for hearing aids. Normal schools are making efforts for the
provision of hearing aids, but special schools are not making special arrangements for
the provision of aid.
3. A survey to assess the parental choice of sign language or spoken language as a
medium of instruction may be conducted and the facilities/provisions for both
approaches of educating HIC may be available in all schools, but 100% provision of
hearing aid and intensive speech perception training is a must for the parents
choosing aural communication. The Punjab Special Education Department must
264
compare the benefits of total communication achieved so far and benefits of the aural
approach of teaching as reported by numerous research studies. At least a pilot project
can be initiated. In my opinion, if basic facilities are there along with professional
training, the chances of success of the aural teaching approach are brighter as
depicted by the teachers’ perception about both approaches.
4. The present research has revealed the impact of availability of multi-professionals in
special schools for HIC in Punjab. Equal focus on the provision of multi-
professionals in schools/centres and on parental training cum involvement is the
ultimate solution to current problems of HIC. Specific arrangements for parental
training like training camps, material for training and awareness (pamphlets,
handouts, etc) must be prepared within a short time period. Moreover, monitoring of
the professional practices of audiologists’ and SLTs needs attention of special
education planners. It is of vital importance that audiological practices in schools may
go beyond the assessment and guidance and may include development and
implementation of auditory training plans, monitoring of classroom acoustics and S/N
ratio, hearing aid benefit analysis, etc. Updating record of each child’s progress in
functional auditory skills may be strictly monitored by the Heads of the institutions or
by an area coordinator (focal person of the area). Similarly, SLTs are ignoring the
auditory skill area and focusing only on speech and language. Intensive therapy,
covering all target areas of aural/oral rehabilitation and record keeping practices are
also in need careful monitoring.
265
5. Persons involved in human resource planning are expected to give attention to the
parental wish and the demands of the professionals, thus availability of team of an
audiologist, and speech therapist in all primary schools/centres may be taken as a
priority than anything else. In higher classes, availability of vocational teachers with
all necessary equipment and materials is necessary. These planners may immediately
revise the policy about seat allocation in all schools and remove the deficient
planning pitfalls, e.g. no seat allocation of either audiologist or the vocational teacher
in all centres located at tehsil level. New appointment of audiologist on vacant posts
and allocation of seats in all tehsil level centres is recommended as per demand of all
stakeholders. During the transitional waiting period (before their recruitment),
teachers training regarding assessment of hearing loss as well as intervention services,
especially auditory skill building training need to be arranged on immediate basis.
6. All the centres at the tehsil level need drastic changes. No doubt they are the most
important source of reaching HIC at the root level of Punjab, but problems like
extreme deficiency of teachers, SLTs, audiologists and even principals, poor
conditioned buildings and dearth of finances even to maintain the provision of
transport are creating a very bad image of Punjab government’s far sighted policy and
planning. Parent teacher associations need to be strengthened in all special education
schools to create finances for parental training, maintenance of hearing aid, etc.
7. The population of HIC is increasing enormously and in nearby future, it is expected
that it would be doubled and would be the maximum if compared with visual
266
impairment, physically disabled and intellectually challenged children, so revision of
seat allocation (equal number of seat allocation for teachers of all four disabilities) is
required.
8. Drastic changes in the curriculum for HIC are suggested at least at primary level.
Development of integrated curriculum having overlapping repetition of targets,
mainly covering all four stages of the languages development i.e. listening, speaking,
reading and writing and provisions for the preparation of working modules or
workbooks are requested from the curriculum wing of special education department.
The curriculum development wing of the special education department may develop a
regular strategy to accommodate the feedback from teachers, professionals and
parents as well as the international trends regarding the education of HIC. Special
education may be the name of special arrangements made for each child’s individual
needs. The concept of IEPs is almost absent in our special schools, therefore,
supporting the whole building of teaching practices on the basis of IEPs is
recommending.
9. The curriculum wing has prepared a syllabus for speech and language development
of HIC from preschool to class three. A child entering a senior class due to his/her
age has to do practice on consonants, without basic voice building and vowel
exercises. Speech is a skill, not a subject. The design of the speech syllabus may be
based on different skill levels. Any newly admitted child must pass the first level and
so on and it may not be affected by HIC’s admission in nursery, K.G or even grade 1.
267
Moreover, the teachers may not wait for the post of the SLT to be filled, and may
start practising on different levels/stages of speech syllabus.
10. There may be homogeneity of academic assessment criteria. The instructions for total
subjects to be taught, total marks of the paper of each subject along with sample
papers may be accompanied with the curriculum booklet. Different subjects, different
assessment styles, different pass marks criterion has been observed in the present
study. Moreover, all the HIC institutions may have contact with vocational training
institutions for training and internship/job placement opportunities of passing out
HIC.
11. Screening camps not only for hearing impairment, but also for other disabilities may
become the common routine of all basic health units. Training of technicians/ staff
along with referral protocol to be followed by parents may be arranged in all basic
health units at the tehsil level.
12. Serious efforts towards prevention of hearing loss are the dire needs of our society.
Extensive involvement of print and electronic media to create awareness about the
debilitating effects of hearing loss in the lives of persons/families and the ways to
decrease its incidence in the families of HIC can be a solution to the problem. It may
be the responsibility of Heads of all HIC special education institutions to have
arrangements for guidance about prevention of the hearing loss.
13. Parental comments like education system is defective, a position holder HIC in board
examination can’t do creative writing, even of few lines properly in English or Urdu
268
language, etc. are red signals for the quality control or monitoring wing of the special
education department. Therefore it is recommended that a research department may
be created by the ministry with a focus on determining cost effectiveness of the
special education services in Punjab.
14. The researcher requested a research grant from Higher Education Commission to
purchase the international models, integrated curricula, tools, etc. but she was refused
by replying that research grant is meant for pure Science subjects only. Current
research was a combination of the Social Science i.e. Education and the sciences i.e.
speech and hearing sciences. Therefore, it is suggested that specific area of research
may be considered and not the general area of degree while taking decision about
research grants to scholars.
15. The researcher requested sponsorship for digital hearing aids to be used in the
experiment, as the number of profound HIC using bilateral digital hearing aid was not
satisfactory to the researcher. Thus small comparison groups of experiment were
made. But again, her request was declined by a minister. It is suggested that hearing
aid production companies may introduce sponsorship of hearing aids for research
purposes. This activity will help them in marketing as well as improving the output of
their products.
16. It was earlier decided by the researcher to randomly select the children of each age
group for pilot study of USPT from local schools. But the request to take the test of
normally hearing children was not met with encouragement from Heads of various
269
schools. Only schools having a personal relationship with the researcher granted the
request. Therefore, it is suggested that all public and private schools be bound by
some law/rules by HEC and the Ministry of education to make a room for researchers
and allow them to conduct their studies comfortably in such a way that the precious
time of both researchers and students of the schools are not wasted.
5.5.2 Recommendations for Future Researchers
17. Urdu Speech Perception Test is a norm referenced, reliable and validated tool for
assessment of auditory skills of HIC. Future research studies to convert it into a
battery can be launched. Extensive research in the area of tool development for
speech and language assessment in our national language is urgently recommended.
18. The research has brought forward the importance of Punjabi language as the main
spoken language in Punjab. Thus, a Punjabi speech perception test development by
future researchers is proposed. Tools for audiological as well as speech and language
assessment need to be developed by the professionals working in the
ministries/departments, in Punjabi and Urdu language. Similarly, tools may also be
developed in other regional languages of Pakistan.
19. For establishing reliability and validity of the USPT, a pilot study was conducted with
130 children only. The study may be replicated by increasing the number of both
normally hearing children and HIC.
20. In survey questionnaires, the ratio of responses to open-ended questions from all five
respondents was very low. Thus, in following need assessment surveys to be
270
conducted annually by the special education Ministry or future researchers, only close
ended items be included to get maximum response from the individuals. Although
combination of both open-ended and closed choice items is the recommended
protocol of questionnaires but, in my opinion, inclusion of open-ended questions does
not suit the Pakistani research culture. Moreover, the results of the annual survey by
relevant ministries/department be published and made available online via the
websites.
21. It was difficult to get any kind of information from the persons working in the
Ministry of special education, Punjab. Moreover, no request either for permission to
conduct the experiment or for an opinion on the CAR model via phone or mail was
granted. Thus the exact population size was not known and the size was estimated. As
a result an estimated number of questionnaires were sent by the researcher. It is
recommended that future researchers may personally collect the demographic data of
the professionals and students from the ministry. Moreover, all the ministries and
departments may be bound to upload the updated information about their assets, staff
details, etc. so that the researchers would be able to get the basic data easily from the
primary sources.
22. Survey questionnaires did not cover the experience, views and opinion of the HIC. At
least a survey of opinions and recommendations by HIC of higher classes may be
conducted to have their perception about the impact of all these budgetary allocations
and professionals’ services.
271
23. Identical writing pattern was personally noticed by the researcher during the data
entry indicating that parental questionnaires were filled with the help of either teacher
of their child or the head of the institution. No doubt, it was helpful to illiterate
parents, but the researcher suspects that this practice was a source of a large number
of no responses and a fewer recommendations made by parents. It is recommended
therefore that the person may not help in filling up the questionnaire, if the
views/opinions about the same person are required. It would be more helpful to the
researcher if planned earlier and she had asked the parents to take help of some third
person. Unbiased and open hearted comments and opinions are more likely to come
to the future researchers if they already plan for this aspect of filling up of the
questionnaires.
24. For the development of the CAR model, only free online material and books were
consulted as it was not possible to purchase the recent models and books costing more
than at least 15,000 rupees each. Various already developed models available online
on payment or in international books must be read before updating the model by
future researchers.
25. For the validation of the model, only one segment was taken. A longitudinal study, in
any one tehsil area covering all aspects of the model is recommended to further
validate the model and to make changes in it, if required.
26. The experimental segment of the research can be repeated by future researchers,
thereby involving all the institutes of any specific area e.g. Rawalpindi. The resultant
272
increase in the number of HIC and numerous auditory trainers will enable the
researcher to compare their performances. This comparison of the trainer and the
trainee can lead to meaningful changes in training outcomes. The research can also be
replicated while increasing the duration of training provided to HIC. A longitudinal
study may be preferred to determine the factors affecting the acquisition of speech
perception skills by the HIC and to assess the transfer of learning.
273
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302
APPENDIX A
Questionnaire for Teachers of Hearing Impaired Children
Name............................... Age...... Male/Female...... Education level.... ………………….
Post (BPS) employed………........... in school/centre name...............................................
Teaching in the centre since…………… Professional qualification………………………
We are conducting a survey on provisions for aural rehabilitation of hearing impaired
children in schools of Punjab. We are contacting you to know in depth about current
practices and provisions and to determine future needs of HIC in schools. Your
participation in the research is very important so you are kindly requested to answer
following questions by checking ( ) next to the appropriate answer or filling the blank
(......).
1/- Number of HIC now in your class, their hearing ability, the number of chilen provided
with hearing aids.
Sr.
no
Name
of child
Age
Degree of the
hearing loss
Provided
with
hearing
aids
Hearing aid type Do they use
aid
regularly
Are they
comfortable
with aid
Right
ear
Left
ear
Yes No
Body
worn
Behind
the ear
Other
Yes No Yes No
1
303
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
2/What are the needs of these children regarding:-
304
- Listening ability development/ provision of hearing aids.............................................
- curriculum development and vocational training............................................................
- teaching method (total communication or aural/listening approach)............................
3/- How do you comment on your use of sign language?
- Rather skillful - Able but not skillful - Very Limited/Very bad
4/- How well, in your opinion, could children in your class use the sign language?
-Rather skillfully -Limited -Almost do not know
5/- How do you rate the children' thinking and reasoning ability when talking (only) with
them about a specific topic/theme?
- Understand mostly - Understand partially - Do not understand
6/- How do you rate the children' thinking and reasoning ability when talking with them
by sign? - Understand mostly - Understand partially - Do not understand
7/- During communication with children, you normally use:
-Sign and speak at the same time -Speak without signing -Sign without speaking
8/- How do these children are provided with speech therapy and what is the children’s
communication level?
Sr.
No
Name
Speech therapy
Sessions/ week
Child’s current communication level
Body/
sign
language
Sounds
(vowels,
grunting)
Words
Ball,b
us etc
2-4 word
sentences
Sentences
longer
than
four
words
Other 1-
2
3-
4
5-6
305
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
306
APPENDIX B
Questionnaire for Parents of Hearing Impaired Children
Name of child......................... Class………… Date of birth................ Male/Female.........
Religion………….. No of siblings……. School/centre name.......................................
Name of father…………… Father’s Education level and occupation.... ………………….
Name of mother…………… Mother’s Education level and occupation.... ………………
Total monthly income of the family……… Other deaf persons in the family…………
We are conducting a survey on provisions for aural rehabilitation of hearing impaired
children in schools of Punjab. We are contacting you to know in depth about current
practices and provisions and to determine future needs of HIC in schools. Your
participation in the research is very important so you are kindly requested to answer
following questions by checking ( ) next to the appropriate answer or filling the blank
(......).
1) Prevalence of hearing impairment in family:-
Relation Name Age Hearing impairment
Father Yes/No
Mother Yes/No
Brothers 1- Yes/No
2- Yes/No
307
3- Yes/No
Sisters 1- Yes/No
2- Yes/No
3- Yes/No
Any other Yes/No
2) When did your child become deaf?
By birth Birth -6 week 6 week - 6 month
7 – 11 months 12 – 24 months over 2 years
3) When (exact age) was he/she diagnosed as deaf? ---------------------------------------------
4) Any other diagnosed disability? --------------------------- Level of disability----------------
5) Information about language and communication at home: -
• What is the main language used at home ---------------------
• What other languages are used at home -------------------------
6 ) Does your child:-
Repeats sounds, words or phrases over and over?
Understand what you are saying?
Points to common objects upon request? (cup, ball etc.)
Follow simple actions? (Shut the door)
Respond correctly to yes/no questions?
Responds correctly to what/ where/ when/ why questions?
308
v.good good average poor v.poor
❖ How well the child communicates with father? 1 2 3 4 5
❖ How well the child communicates with mother? 1 2 3 4 5
❖ How well the child communicates with brother? 1 2 3 4 5
❖ How well the child communicates with sister? 1 2 3 4 5
❖ How well the child communicates with teacher? 1 2 3 4 5
❖ How well the child communicates with others? 1 2 3 4 5
8) Information about current specialised services: ----
Have you as parents had any direct contact with specialised services in the last 12
months: -
Speech and language therapist
Teacher
Audiologist
Psychologist
Social worker
Any other---------------If you have had no contact with some of the above mentioned
specialist, would you like to have contact? Yes No
❖ If yes with whom? ------------------------------------------------------------------
❖ Why? ----------------------------------------------------------------------------------
9) Has your child repeated any grade? Yes No
10) What are your child’s strengths AND weaknesses? -----------------------------------------
-----------------------------------------------------------------------------------------------------------
11) What in your opinion are needs of your child that are neglected by schools and
hospitals ------------------------------------------------------------------------------------------------
12) what in your opinion are most important needs that should get immediate attention by
government --------------------------------------------------------------------------------------------
13) Information about specialist’s services: -
309
(A) On a scale from 1(very much support) to 5(very less support) how much support did
you get as parents from key people around the time when deafness was diagnosed: --
Not applicable
very much support very less support
Paediatrician 1 2 3 4 5
ENT consultant 1 2 3 4 5
Teacher of deaf 1 2 3 4 5
Educational Audiologist 1 2 3 4 5
Hospital Audiologist 1 2 3 4 5
Educational Psychologist 1 2 3 4 5
Speech and language therapist 1 2 3 4 5
Social worker 1 2 3 4 5
Volunteer 1 2 3 4 5
Any one of your family 1 2 3 4 5
Any other---------------- 1 2 3 4 5
Would you have wished to receive support at that time from any of the person listed
above, from whom you didn’t receive support? Yes No
❖ If yes who? --------------------------------------------------------------------------
❖ Why? ---------------------------------------------------------------------------------
❖ Any comment about services which have been provided---------------------
------------------------------------------------------------------------------------------------------
310
(B) On a scale from 1(very much support) to 5(very less support) how much support did
you get as parents from key people around the time when child was at primary school: -
Not applicable
very much support very less support
Paediatrician 1 2 3 4 5
ENT consultant 1 2 3 4 5
Teacher of deaf 1 2 3 4 5
Educational Audiologist 1 2 3 4 5
Hospital Audiologist 1 2 3 4 5
Educational Psychologist 1 2 3 4 5
Speech and language therapist 1 2 3 4 5
Social worker 1 2 3 4 5
Volunteer 1 2 3 4 5
Any one of your family 1 2 3 4 5
Any other---------------- 1 2 3 4 5
❖ Would you have wished to receive support at that time from any of the
person listed above, from whom you didn’t receive support? Yes No
❖ If yes who? ---------------------------------------------------------------------------
❖ Why? ----------------------------------------------------------------------------------
❖ Any comment about services that have been provided------------------------
------------------------------------------------------------------------------------------------------
311
APPENDIX C
Questionnaire for principal/administrator of Hearing Impaired
Children
Name.............................. Age...... Male/Female...... Education level.... ………………….
Working in the school/centre...........................................since…………… on regular/
contract/ adhoc basis …….. Professional qualification………………………………
We are conducting a survey on provisions for aural rehabilitation of hearing impaired
children in schools of Punjab. We are contacting you to know in depth about current
practices and provisions and to determine future needs of HIC in schools. Your
participation in the research is very important so you are kindly requested to answer
following questions by checking ( ) next to the appropriate answer or filling the blank
(......).
1/- In this school/ centre, goals of educating hearing impaired children covers:--
Name of
goals
Choose
Examples of activities
facilities available in
school for the target
Any
achievement
Academic /
literacy
target
Yes/no
Teaching of subjects …
……………………….
Co-curricular Yes/no Sports,………………
312
activities ……………………….
Speech
development
Yes/no
Production of sounds,..
………………………..
Language
development
Yes/no
Vocabulary building, ….
…………………………
Auditory
skill
development
Yes/no
Listening environmental
sounds, ………………
Reading skill
development
Yes/no
Urdu, Eng, ……………
…………………………
Vocational
training
Yes/no
Tailoring, Typing…
………………………..
Social skill
development
Yes/no
Greeting, sharing…
……………………….
313
2/- Does the institute follow any system of identification of hearing impairment?
……………………………………………………………………………………………
3/- Is the institute following any referral system?
……………………………………………………………………………………………
4/- How the institute helps in selection/ fitting and monitoring of amplification devices?
…………………………………………………………………………………………
5/- Is there any kind of financial support given to students for amplification devices?
…………………………………………………………………………………………
6/-How the institute provides guidance and counselling services to the parents?
……………………………………………………………………………………………
7/- Is there any guidance/counselling programme for prevention of hearing impairment?
……………………………………………………………………………………………
8/- Is there any schedule of routine medical checkup by doctors/ ENT consultants?
……………………………………………………………………………………………
9/- How the institute determines and updates the nature and degree of hearing loss of
students?
……………………………………………………………………………………………
10/- What is the schedule of routine audiological assessment of the students?
……………………………………………………………………………………………
11/- Is there any provision for professional development of staff (regarding auditory skill
development training for deaf teachers)?
314
……………………………………………………………………………………………
12/-What training courses, the staff (teachers, audiologist, therapists, etc) has attended
for auditory and communication skill development of HIC in the last five years?
Name of course and
course objectives.
Attended by
which
professional
Duration of
course
(mention dates)
Any
achievement
13/- What trained professionals for auditory skill development are available in school?
…………………………………………………………………………………………
14/- What services for aural rehabilitation are still required by students?
……………………………………………………………………………………………
15/- What major problems are you facing regarding achievement of all above mentioned
goals of your institute?
……………………………………………………………………………………………
16/- How many deaf students have successfully been mainstreamed in normal schools?
……………………………………………………………………………………………
17/- What are your recommendations regarding aural rehabilitation of HIC?
…………………………………………………………………………………………
315
APPENDIX D
Questionnaire for Speech and Language Therapist
Name............................... Age...... Male/Female...... Education level.... ………………….
Post (BPS) employed………....... in school/centre name.............................................
Practising in the centre since…………… on regular/ contract/ volunteer basis…………
Professional qualification………… attained from institute………………………
We are conducting a survey on provisions for aural rehabilitation of hearing impaired
children in schools of Punjab. We are contacting you to know in depth about current
practices and provisions and to determine future needs of HIC in schools. Your
participation in the research is very important so you are kindly requested to answer
following questions by checking ( ) next to the appropriate answer or filling the blank
(......). All replies need to be supported by documentary evidence when required by the
researcher.
1) You have provided speech and language therapy to approximately………… number of
HIC in the last five years.
2) How do these children are provided with speech therapy and hearing aid type in
your centre?
Name
class
Speech-therapy
sessions per
week
Degree
Of
Hearing
Loss
Type of hearing aid Using
a hearing aid
Comfortabl
e
with aid
Body
worn
Behind
the ear other Regular
Not
regular Yes No
1-2 3-4 5-6
316
3) Equipment and material provided to the speech therapy department in school
includes:-
Sound treated test booth
317
Clinical speech therapy room
Equipment and other instruments necessary for assessing young children or
difficult-to-test children
Test materials for screening speech and language and evaluating speech reading,
functional listening, and auditory skills
C.D. player for use with recorded assessment materials
Hearing aids, radio aids, F.M system etc. to be used on a permanent or temporary
basis for evaluation of and intervention for hearing loss
Materials necessary for providing direct and indirect intervention services like
toys, readers, models, flashcard, charts etc.
Furniture appropriate for providing therapy
Sound-level meter with calibrator
Computer for administrative purposes (e.g., generating reports and tracking
student data and outcomes)
4) Record of Assessment and Progress of each child includes the following:-
Case history
Speech Assessment forms
Language Assessment forms
Auditory skill Assessment forms
4-6 monthly progress report
Annual progress report
318
Record of all previous targets
Record of all Current target of therapy
-----% of children’s files have the above mentioned filled forms
5) What is your opinion about current condition and recommendation need about the
followings in your institute?
S/No of Itemsنمبر شمار
Current condition in
school
سکول میں موجود صورت حال
Future needs مستقبل کی
ضرورت
Collaboration with teacher
استاد سے تعاون
Communication with parents والدین
سے بات چیت
Parental guidance and counselling
services
والدین کی سرپرستی اور مشاورت کی
خدمات
Support from administration
انتظامیہ کی جانب سے مدد
Training of teachers
تاساتذہ کی تربی
Provision of hearing aid to
children
بچوں کو آلہ سماعت کی فراہمی
Facilities for auditory training
of the children
بچوں کی سمعی تربیت کی سہولیات
Training of therapist for auditory
skill development of children
بچوں کی سمعی مہارت میں ترقی
متعلق تھیراپسٹ کی تربیتسے
Speech therapy Work load
سپیچ تھیراپی کی استعداد کار
319
6) Auditory profile of all students being provide with speech therapy is:-
Name Class
Has awareness of loud
(can detect)
Monitor
status of
aid by
vocalising
Search for
source of
sound
( can localise)
Can
discriminate
sounds like
Environmental
sounds
Speech
Sounds
Loud
sound music
Loud
/soft
Teacher
/ student
7) Auditory profile of each child provided with therapy is:-
320
Name Class
He/she can identify(when listening only) He/she can
repeat words
( when
listening
only)
Sounds e.g.
/b/, /t/, /l,/.
(Mention all sounds
which he/she can
listen)
Body
parts
Common
Objects
Colours,
own
name 1-2 3-4 5-
6
321
APPENDIX E
Questionnaire for Audiologist
Name.................................. Age...... Male/Female...... Education level.... ……………
Post (BPS) employed………...........in school/centre name..............................................
Practising in the centre since…………… on regular/ contract/ volunteer basis………
Professional qualification…………………attained from institute……………………
We are conducting a survey on provisions for aural rehabilitation of hearing impaired
children in schools of Punjab. We are contacting you to know in depth about current
practices and provisions and to determine future needs of HIC in schools. Your
participation in the research is very important so you are kindly requested to answer
following questions by checking ( ) next to the appropriate answer or filling the blank
(......). All replies need to be supported by documentary evidence when required by the
researcher.
1) Normally determination of nature and degree of hearing loss is done in the centre at
time of :-
Entry into the centre
6- month interval
End of each academic year
Demand of teacher /therapist
/parents
Still not done
Others---------------
2) Equipment and material provided to the audiology department in school includes:-
322
Sound treated test booth
Clinical audiometer with sound field capabilities
Visual reinforcement audiometry equipment and other instruments necessary for
assessing young children or difficult-to-test children
High fidelity tape/C.D. player for use with recorded assessment materials
Visual reinforcement audiometry equipment and other instruments necessary for
assessing young children or difficult-to-test children
Electrophysiological equipment (e.g., screening and/or clinical OAE/ABR
equipment)
Portable audiometer
Clinical and portable acoustic immittance equipment
Otoscope
Electro acoustic testing equipment (e.g., hearing aid analyser, real ear
measurement system)
Hearing aids and HATS to be used on a permanent or temporary basis for
evaluation of and intervention for hearing loss and/or APD
Ear mould impression materials and modification equipment
Sound-level meter with calibrator
Test materials for screening speech and language and evaluating speech reading,
functional listening, and auditory skills
Materials necessary for providing direct and indirect intervention services
323
Computer for administrative purposes (e.g., generating reports and tracking
student data and outcomes)
Sterilisation/sanitation supplies necessary for practising universal precautions
3) Comprehensive Audiological assessment of each child in the centre includes:--
Case history
Otoscopic examination
Acoustic immittance audiometry
Pure tone audiometry
Speech recognition threshold
(quiet)
Speech recognition threshold
(noise)
Word recognition
measures(auditory only)
Word recognition measures
(auditory and visual)
Most comfortable loudness level
Uncomfortable loudness level
Electro physiologic tests (ABR,
OAE)
Auditory processing test battery
Play audiometry
Functional listening skill
4) Practice of selection, administering, scoring, and interpreting tests to determine the
benefits of hearing aids, cochlear implants, FM systems etc in the school include the
following:--
Speech audiometry (in quiet and
noise; auditory and auditory-
visual)
Functional measurements
Real ear measurement
Desired sensation level
measurement
Electroacoustic analysis
324
Listening and speech sound
checks
Auditory skill development
measurement
5) Intervention services provided to the hearing impaired children in the centre/school
include the following:--
Medical treatment, when indicated.
Selection, fitting, and dispensing of appropriate amplification at the earliest
possible age.
Ensuring hearing aid compatibility with other technology devices and systems in
use (e.g., computers, augmentative/alternative communication [AAC] devices and
systems, infrared systems).
Auditory skill development training.
Training in the use of hearing aids with other types of technology and in various
environments (e.g., computers, AAC devices and systems, noisy classrooms,
social situations).
Structuring a successful learning environment that includes teacher preparation,
optimal room acoustics, accessibility to auditory and visual information, and peer
and teacher orientation and training.
Development and remediation of communication in collaboration with speech
language pathologists.
Development of compensatory strategies such as the use of visual information to
supplement auditory input.
325
Academic tutoring or specialised instruction.
Counselling and self-advocacy training.
Facilitation of, access to, participation in, and transition between programmes,
grade levels, agencies, vocational settings, and extracurricular activities.
Appropriate medical, educational etc. referrals to other services.
6) Comment on existing and need of in-service training of teachers regarding aural
rehabilitation.
7) Comment on existing scenario and need of collaboration among rehabilitation
professionals.
8) Comment on existing as well as need of screening facilities available in our
community.
326
APPENDIX F
List of the Focal Persons held Responsible to Collect and Send
Questionnaires
Name Address
Maryam Aftab
Sir Syed school & college for HIC, Mohammad Hussian
road,
opp. FWO HQ, Rwp. 0334-5042639
Naveed Shahzad
Govt. Deaf & Defective hearing school, Rajanpur.
0333-6454305
Ayesha Raza
Shalimar special education centre for HIC, Lahore. 0334-
4455323
Aziz ul Hassan
Govt. school of special education for Hearing Impaired,
Vehari. 0300-7731345
Malik Rustam
Govt. Deaf & Defective Hearing school, Tatral road,
Chakwal. 0331-5022947
Muhammad Akmal
Sahib
Office of the District Education Officer
(special Education) Faisalabad. 0321-5351387
Madam Saeeda
Sahiba
Govt. Deaf & Defective hearing school,
Swan camp, G.T road Rwp.
Muhammad Hussain Govt. special Education Centre for HIC,
327
Tahir opposite new stadium, Rahim Yar Khan. 0300-9675853
Sarwat Nawaz
Govt. Deaf & Defective Hearing School, Sargodha.
0321-6003314
Miss Shumaila
Govt. special education centre Thana road,
Kallar Sayedan Rawalpindi. 0300-9772192
M. Asif Sarwar
advocate
Special Education Degree college Jangee Wala,
Bahawalpur. 062-2282142
Syed Maheen
Hussain
Govt. special education centre for HIC, Jhang.
Azhar Sajjad
Govt. degree college 45B-2, Johar town,
Lahore. 0300-4828767
Mr. Imran Okara. 0333-5599930 (responsible for five other cities also)
Saqibafzal Sheikhupura. 0300-4493946
Misbahkausar Gujrat. 0533-5122708
Nazir Hussain Bhakkar. 0345-4680714
M. Riaz D.G khan. 0311-4232255
Dr. Anwar Ahmed Gujranwala. 0333-8235703
Shahida Tufail Bahawalpur. 0312-7432447
Itifaq Ahmed Multan. 0307-7457975
Abdul Hakeem Sahiwal. 0302-6928182
328
APPENDIX G
Questionnaire for experts to critically appraise the CAR model for Pakistan
Note: I Hina Noor, speech therapist is doing Ph.D from Foundation University. My research
title is “Development and Validation of Model of Aural Rehabilitation for Profound HIC in
Punjab”. I have contacted you to give you opinion about the proposed Aural Rehabilitation
Model for HIC in Pakistan; Your opinion is very important for validation of this model.
Please write your opinion covering these aspects of model development.
Q1. Does the proposed model is parallel to the current international trends and practices
in aural rehabilitation?
Q2. Does the proposed model covers all relevant components and functions of aural
rehabilitation?
Q3. Is the Model in accordance with Pakistan’s cultural & socioeconomic condition?
Q4. What are the strengths of the proposed model?
Q5. What are the weakness present in the model and your suggestion to further improve
it?
Q6. Does the proposed model clearly indicate the problem/ issue to be solved?
Q7. Does the proposed model will be able to bring the desire change in the community?
Q8. Does the proposed model accurately describe the programme details and intended
results?
Q9. Does the proposed model highlights the assumptions i.e. beliefs, ideas & theories of
the model?
Q10. Does the proposed model cite the influential factors?
329
APPENDIX H
Sr. Persons Rank Comments
01
02
03
04
Dr. Shaista Majid
Dr. Munir
Dr. Ayesha Butt
Ishrat Masood
Assistant Professor AIOU
Principal Army Special
Education
Coordinator of special
pathology department in
Riphah university
Acting D.G of special
education, Islamabad
She appreciated the model and
recommendation to add few points.
He proposed the inclusion of early
detection and fitting of aid before
three months of age. So screening
cells were included.
She pointed out the combination of a
range of models tailored for over
system as models main strength. She
was worried about the presence of
multidisciplinary team in centers
which is assumed provision of this
model.
She emphases on provision of hearing
aids and technical training facilities
was agitated by lack of professional
honesty, dedication and commitment
330
05
06
07
08
09
Dr. Shahbaz A Khalid
Mr. Miraj Gul
Farah Rahman
Dr. shaista habibullah
Assistant Professor
(Nero rehabilitation)
Mr. Munir Akhter
Qureshi ,Visiting
faculty of Ayub
Deputy Director NTSCP,
Islamabad
Director DGSE, CADD
Islamabad
Senior teacher NISE
Director NIRM Islamabad
Director planning and
finance CADD DGSE,
in special education center
He liked the economic and cultural
aspects of the model and proposed a
few recommendation which were
incorporated
He was surprised by the statement that
aural rehabilitation of profound deaf
is possible.
She stressed (in parallel with
researcher) on development of Aural
Communication and environment
modification for rehabilitation of HIC.
She really liked the model and
compares it with storm in a tea-cup.
He emphasized on inclusion of
religious component in integrated
curriculum of wanted the researcher
331
10
11
12
Medical College
(Medical Sociology)
subject in women
medical college.
Mr. Cheema
Azhar sajjad
Dr. Irfan
Islamabad
Director special
Education Ministry,
Lahore Punjab
Deputy director special
education Lahore
Audiologist NSEC,
Islamabad HIC
to mention the age group and mental
abilities of the targeted beneficiaries.
Model was not sent back with
comments or suggestions.
Model was not sent back with
comments or suggestions
Model was not sent back with
comments or suggestions
All the changes proposed by the experts and professional were fully incorporated with the
aim of improvement in the proposed model of AR of HIC
332
APPENDIX I
Questionnaire for professionals to check content validity of the proposed Urdu
Speech Perception Test for HIC
Note:I, Hina Noor, Ph. D Scholar is developing and validating a speech perception test
in Urdu language. You are contacted here to comment on the structural composition and
items selection of this test. Please tick on the Likert scale. Feel free to write your
comments and suggestion. For any query contact me at (03005182901).
Detection
Target: Child will be able to detect the high and low frequency environmental and
speech sound.
Q. Is the target of detection, relevant to speech perception test? Yes No
Any suggestion:______________________________________________________
Stimulus used:
i Door knock Yes No
iii Clap sound Yes No
iii / آ / Yes No
iv / n / Yes No
v / l / Yes No
vi / k / Yes No
vii ای Yes No
333
vii / b / Yes No
ix / t / Yes No
Q. Do the stimuli used here match/ represent the target?Yes No
Any suggestion:______________________________________________________
Discrimination
Target: Child will be able to discriminate between.
i. Environmental and speech sounds.
ii. Mono and bi-syllabic words.
iii. Constant, at initial, middle and final position.
Q. Is the target of discrimination relevant to speech perception test? Yes
No
Any suggestion: ________________________________________________________
Stimulus used:
i Drumbeat vs Drumbeat Yes No
ii Horn vs Flute Yes No
iii Piano vs a آ Yes No
iv Oاوvsام Yes No
v تتلیvsتیل Yes No
vi پاکستانvs پاکستان Yes No
334
vii حلوهvsحلوای Yes No
viii شیرvsشیر Yes No
ix Penvs Pin Yes No
x چوکvs چاک Yes No
Q. Do the stimuli used here match/ represent the target?Yes No
Any suggestion: ____________________________________________________
Part 2 of Discrimination (involves tasks of auditory memory).
Q. Which one of the three words is different from others:-
s.no Words 1st word 2nd word 3rd word
i. ڈور مور مور
ii. سرف برف برف
iii. ہاته ساته ہاته
iv. سولہ صوفہ صوفہ
v. ابا ابا اڈه
vi. حاتم حاتم حاکم
vii. بال بات بات
viii. تین تین تیر
ix. سیب سیل سیل
335
x. سب بم بس
Q. Do the stimulus words represent the target? Yes No
Any suggestion: ___________________________________________________
Identification
Target:Child will be able to identify (repeat or point to) these phonetically balanced
word list.
Q. Does the target relevant to the task of identification in speech perception test?Yes
No
s.no
Mono-syllabic
words
Do the words represent the
target
Bi-syllabic
words
Do the words represent the
target
i. Pen Yes No بلی Yes No
ii. Car Yes No آڻا Yes No
iii. Cake Yes No کیال Yes No
iv. Van Yes No ماچس Yes No
v. Gate Yes No آڑو Yes No
vi. Jug Yes No صوفہ Yes No
vii. شیر Yes No ہاکی Yes No
viii. ہاته Yes No انڈه Yes No
ix. مور Yes No بازو Yes No
336
Q. Do the stimulus words represent the target? Yes No
Any suggestion: ___________________________________________________
Comprehension
Target: Child will be able to understand these questions and answer them
properly.
Q. Is the target of discrimination relevant to speech perception test? Yes
No
Any suggestion: ________________________________________________________
Stimulus questions represent.
Yes No 1 آپ کانام کیا ہے؟.
Yes No 2 آپ کو کونساپهل پسندہے؟.
Yes No 3 بکری کیاکهاتی ہے؟.
Yes No 4 پانچ رنگوں کے نام بتانیں؟.
Yes No 5 آپ کے کتنے بہن بهای ہیں؟.
Q. Do the above mentioned questions represent the target? Yes No
Any suggestion: ________________________________________________________
x. 2 دو Yes No طوطا Yes No
xi. ہار Yes No ہاتهی Yes No
xii. سانپ Yes No Yoyo Yes No
337
APPENDIX J
LIST OF PROFESSIONALS AND THEIR DESIGNATIONS WHO HAD
COMMENTED ON CONTENT VALIDITY OF THE USPT
Sr. Name Designation Institution Comments
01
Dr. M Waseem
Anjum
HOD of Urdu
Department
Federal Urdu
University,
Islamabad
He commented that test
developed by the
researcher in Urdu
language is a new
experience and the
progress made is
satisfactory.
02
Dr. Fehmida
Tabassum
Assistant
Professor
Federal Urdu
University,
Islamabad
She commented
on the work as an
excellent effort.
03
Dr. Munawar
Hashmi
Professor
Federal Urdu
University
Islamabad
He appreciated
the work.
04 Dr. Ayesha Butt
Speech
Pathologist
Riphah
University,
Islamabad
She recommended to
study the Clinical
Evaluation of Language
338
Fundamentals test
(CELF) and introduce
the researcher with
the term of Language
Code Switching.
05 Ruby Irum
Speech
therapist
Sir Syed school
and college for
Deaf
She appreciated the
effort and demanded
the copy of test.
06 Miss sajida
Speech
therapist
National
Institute
of Special
Education,
Islamabad
She suggested to
use statements carrying
ICWs for the task of
comprehension.
07 Dr. Irfan Ahmed Audiologist
National
Institute
of Special
Education,
Islamabad
He suggested to
exclude environmental
sounds from task of
detection and
discrimination and
to include Ling six sounds
in detection task.
Moreover to represent
339
the task of
comprehension only
he suggested a finger
pointing test
instead of using
questions as stimuli.
08
Mr. Wasim
Akhter
Audiologist
National
Institute
of Special
Education,
Islamabad
Despite several visits
and requests, he
refused to gave
comments with an
excuse that speech
perception testing does
not come under his
domain of practice.
09
Mrs. Samina
Ibrahim
Audiologist
National
Institute
of Special
Education,
Islamabad
She also refused
to give any comment
or suggestion.
340
APPENDIX K
Questionnaire to rate the familiarity of these words of Urdu
Name:___________________________ Age:_________ Sex:____________
Mother tongue:__________________Second language:____________________ District
of Domicile:___________________ Residence at present:___________
_____ _ Contact no: _____
Note: Please tick the relevant box to rate the familiarity of these words to you.
S.no Words Very
common
Common Not
common
S.no Words Very
common
Common Not
common
بال 15 ابو 1
ببل 16 آڻا 2
بس 17 آڻه 3
بستہ 18 اڻهو 4
بکری 19 اچها 5
بندر 20 آڑو 6
بوتل 21 آلو 7
پانچ 22 امی 8
341
S.no Words Very
common
Common Not
common
S.no Words Very
common
Common Not
common
پانی 23 انار 9
پاوں 24 آنکه 10
پتا 25 انگور 11
پتهر 26 ایک 12
پرس 27 بابا 13
پرس 28 بازو 14
جوتا 48 پل 29
جیب 49 پلیٹ 30
چار 50 پنسل 31
چار 51 پنکها 32
چاند 52 پیال 33
چپل 53 تار 34
چڑیا 54 تاال 35
چینی 55 تاال 36
خرگو 56 تتلی 37
342
S.no Words Very
common
Common Not
common
S.no Words Very
common
Common Not
common
ش
خوبانی 57 تربوز 38
دال 58 تکیہ 39
دانت 59 تین 40
دروازه 60 ڻافی 41
دس 61 ڻانگا 42
دم 62 ڻوپی 43
2دو 63 ڻوکری 44
دوا 64 جاؤ 45
دوات 65 جراب 46
دودھ 66 جگ 47
عینک 85 ڈبہ 67
غباره 86 ڈنڈا 68
فواره 87 ڈول 69
کاپی 88 رات 70
343
S.no Words Very
common
Common Not
common
S.no Words Very
common
Common Not
common
کار 89 رکشہ 71
کاال 90 زبان 72
کپ Zip 91زپ 73
کتا 92 سات 74
کرسی 93 سانپ 75
کمره 94 سب 76
وا 95 سبز 77 ک
78
Staسٹار
r
کوٹ 96
کولس 79 کیک 97
کیال 98 سیب 80
گاجر 99 شیر 81
گاۓ 100 صابن 82
گالس 101 صوفہ 83
گم 102 طوطا 84
344
S.no Words Very
common
Common Not
common
S.no Words Very
common
Common Not
common
Gum
ناک 122 گنده 103
نان 123 گهوڑا 104
نرس 124 گوبهی 105
نہیں 125 گیٹ 106
9نو 126 الل 107
ؤ 108 ہاته 127 ال
ہاتهی 128 لٹو 109
ہار 129 لوا 110
ہاکی 130 لوڻا 111
وه 131 لیموں 112
وہاں 132 مالٹا 113
وین 133 مرچیں 114
یہ 134 مڑ 115
یہاں 135 مکهی 116
345
S.no Words Very
common
Common Not
common
S.no Words Very
common
Common Not
common
YoYo 136 مور 117
میز 118
میں 119
ناریل 120
ناشپاتی 121
346
APPENDIX L
List of the person who rated familiarity of the 168 Urdu words, that served as a pool
for selection of PB words of USPT.
Name District of domicile First language Second language
Nusrat Naheed Jhang Punjabi Urdu
Muhammad Akhter Narowal Punjabi Urdu
Saeeda Iqbal Gujrat Punjabi Urdu
Muhammad Nafees Sialkot Punjabi Urdu/English
Abdul Haq Faisalabad Punjabi Urdu
Mushtaq Ahmed Sargodha Punjabi Urdu
Fakhra Batool Chakwal Punjabi Urdu
Afrasayab Zafar Peshawar Urdu Pashto
Anar Gul Attock Pashto Urdu
Nahid Attock Punjabi Urdu
Sofia Punjab Punjabi Urdu
Ghulam Rasool Ghanchi Balti Urdu
Shamsa Ashfaq Azad Kashmir Urdu Urdu
Rubina Rauf Punjab Pothowari Urdu
Riffat Nazli Rawalpindi Punjabi Urdu
347
APPENDIX M
Urdu Speech Perception Test
Instruction for the tester/scorer
1. All the four areas i.e. detection, discrimination, identification and
comprehension will be tested while listening to the task only. No chance of lip reading.
2. Present the stimulus from back of the child and hide all sound sources.
3. Maintain the distance of at least 4-6 feet between you and the child.
4. Maintain good lightening condition in the room.
5. There should not be any sound distraction near the room.
6. Age range of children that can be tested is 4-14.
7. Try to maintain your uniform sound volume. Only raise the volume once if child
is not picking/detection your sound.
8. You can take the take in 2-3 sittings if needed for very young children.
9. First get full attention of child then present the sound stimulus.
10. Avoid repetition as far as possible (maximum two times)
11. In case of HIC, child should be wearing his/her aid in both ears.
12. Score during testing, against each item separately each item carries one mark.
13. Arrange things mentioned in comprehension task beforehand.
14. Up to 6 years of age present the pictures of identification task in two separate
groups as and can replace.
15. For any query please contact me at (0300-5182901)
348
Detection
Target: Child will be able to detect the following high and low frequency speech
sounds when presented from the back of the child.
i / a / • Yes • No
ii / o / • Yes • No
iii / e / • Yes • No
iv / m / • Yes • No
v / l / • Yes • No
vi / k / • Yes • No
vii / s / • Yes • No
vii / h / • Yes • No
ix / ž / • Yes • No
x / th /
Discrimination
Target: Child will be able to discriminate between these two sound stimuli while
listening to them blindfolded.
i /a/ vs /o/ Yes No
ii /o/ vs /aap/ Yes No
iii ball vs bell Yes No
iv tea vs two Yes No
349
v تتلیvsتیل Yes No
vi پاکستانvs پاکستان Yes No
vii حلوهvsحلوای Yes No
viii شیرvsشیر Yes No
ix pen vs pin Yes No
x چوکvs چاک Yes No
Part 2: Disrimination
Q. Which one of the three words is different from others:-
s.no Words 1st word 2nd word 3rd word
xi. ڈور مور مور
xii. سرف برف برف
xiii. ہاته ساته ہاته
xiv. سولہ صوفہ صوفہ
xv. ابا ابا اڈه
xvi. اتمح حاتم حاکم
xvii. بال بات بات
xviii. تین تین تیر
xix. سیب سیل سیل
xx. بس بم بس
350
Identification
Target: Child will be able to identify (repeat or point to) these phonetically balanced
word list.
s. no
Mono-syllabic
words
Child’s response (correct)
Bi-syllabic
words
Child’s response (correct)
xiii. Pen Yes No بلی Yes No
xiv. Car Yes No آڻا Yes No
xv. Cake Yes No کیال Yes No
xvi. Van Yes No ماچس Yes No
xvii. Gate Yes No آڑو Yes No
xviii. Jug Yes No صوفہ Yes No
xix. شیر Yes No ہاکی Yes No
xx. هہات Yes No انڈه Yes No
xxi. مور Yes No بازو Yes No
xxii. 2 دو Yes No طوطا Yes No
xxiii. ہار Yes No ہاتهی Yes No
xxiv. سانپ Yes No Yoyo
Yes No
xxv. انگور Yes No
351
Comprehension
Arrange these things infront of the child before start of the comprehension task.
• Three pens/ball points of different colours.
• Three markers of different colours (having red).
• Three pencils of different colours(+green) with/without eraser(red coloured) at the
end.
• Three pencils of small sizes with green and other colours.
• Erasers of different sizes and colours.
Target: Child will be able to respond properly to these statements.
1. Give me a pen.
2. Give me red marker.
3. Show me small green pencil.
4. Show me green pencil with red eraser at end.
5. Show me the smallest eraser.
No yes
yes
yes
yes
yes
No
No
No
No
352
353
APPENDIX N
Speech Perception Test Scores of Children of the Pilot Study of USPT
Name Age Class Q1 Q2 Q3 Q4 Total
1 Zoya Shehzadi 4 years nursery 10 18 18 4 50
2 Sawera tahir 4 years nursery 10 20 22 3 55
3 Omama 4 years nursery 10 19 22 5 56
4 Zainab Noor 4 years nursery 10 15 21 2 48
5 Ayesha 4 years P.G 10 18 23 4 55
6 Seyam 4 years P.G 10 15 25 3 53
7 Mehak 4 years P.G 10 17 25 3 55
8 Abdullah Moiz 4 years P.G 8 13 22 5 48
9 Haris 4 years P.G 9 13 24 3 49
10 Hammad 4 years nursery 10 18 23 3 54
11 Aqsa jameel 5 years nursery 10 17 22 3 52
12 Mahanoor 5 years nursery 10 16 22 5 53
13 Amna Khalid 5 years P. nur 10 17 24 5 56
14 Saif ur Rehman 5 years P. nur 10 14 18 3 45
15 M. Soman 5 years K.g 10 17 18 3 48
16 Pakeza 5 years K.g 10 14 21 5 50
17 M. Mustafa 5 years K.g 10 18 25 5 58
354
18 M. rehan 5 years K.g 10 18 22 2 52
19 Ibrahim 5 years K.g 10 17 20 4 51
20 Minahil 5 years nursery 8 13 22 5 48
21 Ailka Nisar 6 years K.g 10 17 22 4 53
22 Bushra Yahya 6 years K.g 10 17 25 3 55
23 Qurat-ul-Ain 6 years K.g 10 20 22 4 56
24 M.bin Farooq 6 years K.g 10 20 21 4 55
25 Areeba Khalid 6 years K.g 10 17 23 5 55
26 Huda Jawad 6 years 1st 10 16 25 5 56
27 Areeba Tahir 6 years 1st 10 19 24 5 58
28 Jawaria Sajjid 6 years 1st 10 18 23 5 56
29
Khadija
Hammad
6 years 1st 10 18 22 5 55
30 Maira 6 years K.G 10 17 21 3 51
31 Uzair 7 years 1st 10 17 24 5 56
32 Zohaib 7 years 1st 10 18 25 5 58
33 Noor 7 years 1st 10 18 24 5 57
34 Shair vali 7 years 1st 10 16 20 3 49
35 Kalsoom 7 years 2nd 10 19 25 5 59
36 Maryam 7 years K.g 10 15 23 5 53
37 Adil yahya 7 years K.g 10 18 24 5 57
355
38 amna afifa 7 years 1st 10 19 22 5 56
39 Zona Zahid 7 years 1st 10 19 25 5 59
40 Muzakir 7 years K.g 10 16 24 5 55
41 Fahad 8 years 1st 10 17 24 5 56
42 M. Hassan 8 years 2nd 10 17 24 5 56
43 Noor Fatima 8 years 2nd 10 18 24 5 57
44 Umair 8 years 2nd 10 17 22 5 54
45 Warisha 8 years 2nd 10 18 22 5 55
46 Bushra 8 years 2nd 10 16 25 5 56
47 shayan 8 years 2nd 10 19 25 5 59
48 Dua jawad 8 years 2nd 10 17 22 5 54
49 Ahmad ali 8 years 3rd 10 17 24 5 56
50 Mahnoor 8 years 3rd 10 20 25 5 60
51 Imran Khan 9 years 1st 10 20 25 5 60
52 Abdullah Haris 9 years 2nd 10 19 24 4 57
53 Abdullah Iqbal 9 years 3rd 10 19 24 5 58
54 Habiba akhter 9 years 3rd 10 20 25 5 60
55 Rabia Abid 9 years 3rd 10 20 24 5 59
56 Maryam 9 years 3rd 10 17 25 5 57
57 Shafique 9 years 1st 10 16 22 4 52
58 dua 9 years 3rd 10 16 21 5 52
356
59 Iqra 9 years 4th 10 20 25 5 60
60 Samar 9 years 4th 10 19 24 5 58
61 Sadam Ali 10 years 5th 10 15 25 5 55
62 Laiba Nasir 10 years 3rd 10 20 24 5 59
63 Abdul Moiz 10 years 3rd 10 16 22 5 53
64 Mahmood Ali 10 years 3rd 10 17 25 4 56
65 Laiba Sajid 10 years 3rd 10 14 24 5 53
66 M. Abdullah 10 years 3rd 10 16 22 5 53
67 Mahnoor 10 years 4th 10 17 24 5 56
68 Saima 10 years 4th 10 20 23 5 58
69 Rabiya 10 years 4th 10 19 24 5 58
70 M. Talha 10 years 4th 10 16 25 4 55
71 Raja Khan Viaz 11 years 3rd 10 17 19 5 51
72 Sawaira 11 years 3rd 10 16 21 5 54
73 Haseeb 11 years 4th 10 18 24 5 57
74 Saif Ullah 11 years 4th 9 19 24 5 55
75 Alisba 11 years 5th 10 18 25 5 58
76 Sumayya 11 years 5th 10 18 24 5 57
77 Ali Raza 11 years 3rd 10 19 23 5 57
78 Areeba 11 years 4th 10 16 25 5 56
79 Laiba Nasir 11 years 3rd 10 19 23 5 57
357
80 Laiba sajjad 11 years 3rd 10 14 24 5 53
81 Amara 12 years 5th 10 20 25 5 60
82 Raees 12 years 4th 10 19 24 4 57
83 Raja Jamshad 11 years 5th 10 19 25 5 59
84 Urooj 12 years 5th 10 19 25 5 59
85 M. Usman 12 years 3rd 10 20 25 5 60
86 Arif Iqbal 12 years 3rd 10 18 25 5 58
87 Shaista 12 years 4th 10 16 21 5 52
88 Mubashir 12 years 5th 10 20 25 5 60
89 Hammad 12 years 4th 8 17 24 5 53
90 Laiba 12 years 4th 10 16 25 5 56
91 Shaista 13 years 5th 10 17 24 4 55
92 M. Salman 13 years 3rd 10 16 22 5 53
93 Samiya 13 years 5th 10 17 24 5 56
94 Fatha 13 years 5th 10 20 24 5 59
95 Abdullah Azfar 13 years 7th 10 19 25 5 59
96 Saman Ilyas 13 years 4th 10 19 24 5 58
97 Abdullah 13 years 7th 10 19 24 5 58
98 Ummara 13 years 4th 9 18 25 5 57
99 Muskan 13 years 4th 9 20 25 5 59
100 Shahina 13 years 4th 8 17 22 5 52
358
Hearing Impaired Children
Name
Hearing
Loss
Marks obtain
with hearing aid
Q1 Q2 Q3 Q4
1 Mudasir Pro found 11 7 4 0 0
2 Saim Pro found 3 3 0 0 0
3 Laiba Kiyani Pro found 9 9 0 0 0
4 Minahil Pro found 13 7 6 0 0
5 Tania Pro found 5 3 2 0 0
6 Ayesha Pro found 6 4 2 0 0
7 Areej Pro found 0 0 0 0 0
8 Masoom Pro found 2 2 0 0 0
9 Komal Pro found 7 5 2 0 0
10 Darim Pro found 2 2 0 0 0
11 Wahab Pro found 4 4 0 0 0
12 Faisal Pro found 17 8 8 1 0
13 Raza Pro found 16 8 6 2 0
14 Shahid Pro found 2 2 0 0 0
15 Arslan Pro found 0 0 0 0 0
16 Rabia Pro found 4 4 0 0 0
17 Shah Talib Pro found 9 7 2 0 0
359
18 Haseeb Pro found 6 6 0 0 0
19 Taneer Pro found 12 5 7 0 0
20 Zoia Pro found 21 7 9 5 0
21 Shanza Pro found 11 6 5 0 0
22 Sawaira Pro found 16 6 10 0 0
23 Ahmed khitab Pro found 13 7 6 0 0
24 Iman Noor Severe 11 6 5 0 0
25 Habiba Severe 11 6 4 0 0
26 Alina Severe 18 8 10 0 0
27 Laiba Severe 24 10 10 4 0
28 Adeela Severe 42 8 8 25 1
29 Iman Fatima Severe 23 9 2 12 0
30 M. Ibrahim Severe 43 9 8 25 1
360
APPENDIX O
Speech Perception Test Scores to Determine Reliability of USPT
INTER-EXAMINER RELIABILITY TEST-RETEST RELIABILITY
Name Scores By
Saima
Scores By
Hina
Name 1st attempt 2nd attempt
Myra 51 51 Sawaira 54 55
Omama 56 57 Mahnoor 53 53
Noor 57 58 M bin Farooq 55 56
Maryam 53 57 Adil yahya 57 58
Ibrahim 51 51 Fahad 56 56
Abdullah
Haris
57 52 Rabia 59 60
Saifullah 55 60 Laiba Nasir 59 59
Hammad 53 54 Haseeb 57 55
Arif 58 59 Raees 56 56
Shaista 52 55 Saman 58 57
361
SPLIT HALF RELIABILITY
Name Scores of even items Scores of odd items
ZoyaShehzadi 25 25
Aqsa Jamil 26 26
Jawaria 28 28
Mahnoor 30 26
Dua 26 26
Iqra 30 30
Uzair 26 30
Haseeb 28 29
SamanIlyas 29 28
Areeba 28 28
362
APPENDIX P
Application for Permission to Conduct Experiment in Punjab
Government Schools
The Director,
Government Of Punjab,
Special Education Department,
31-Sher Shah Block, New Garden Town, Lahore.
Subject: Permission to Conduct Experiment in HICSchool / Centre of
Rawalpindi
Respected Sir,
Assalam-o-alaikum
I, Hina Noor, Ph. D scholar of Foundation University is requesting hereby for
approval to conduct experimental training for validation of my research. My topic of
research approved by Board of Advanced Studies and Research (BASR) is
“Development and Validation of Model of Aural Rehabilitation of Profound
Hearing Impaired Children in Punjab- an Experimental Study.”
After development of the model, I am at the stage of its validation through
experimentation. My residential city is Rawalpindi. Therefore, it is convenient for me to
conduct the experimental study in the District of Rawalpindi. Any HICSchool / Centre
having children with behind the ear digital hearing aid will be selected for
363
experimentation.The training of 4-6 weeks will be provided to develop the listening skills
in profound HIC of the school.
It is therefore humbly requested to please allow me to choose the school/centre
and provide training for an hour daily, so that the stage of experimentation can begin
without any further delay. The results of the study will propose the recommendations for
the academic setup of these children and are likely to bring desired changes in the lives of
HIC.
Thanking you in anticipation.
Yours truly,
Hina Noor
House No. 169, Lane 3-B,
Judicial Colony Near
Gulzar e Quaid,
Rawalpindi
Phone No. 0300-5182901
The same application with necessary amendments was forwarded to the
administrator of Sir Syed Academy Rawalpindi after getting no response from the
director special education, Lahore
364
APPENDIX Q
Speech Perception Test Scores of HIC of Comparison Groups of the Experiment
Control Group Experimental Group
Age
Group
Name Pretest Posttest Name Pretest Posttest
4-9 years
Arsalan 0 0 Taneer 12 30
M. Shahid 2 0 Darim 2 15
Rabia 4 5 Eman 11 28
Saim Ali 3 9 Mudasir 11 38
Laiba 24 31 Ahmed 13 37
Rida 10 12 Minahil 13 26
10-14
years
Faisal 17 15 Habiba 11 23
Alina 18 35 Tania 5 25
Masoom 2 4 Haseeb 6 24
Zoia 21 14 Sawaira 16 36
Ayesha 6 7 Shanza 11 32
M. Haseeb 6 7 Wahab 4 26
365
APPENDIX R
Request of research grant/ donation of hearing aids required for conduction of
experimental study in Punjab in the field of aural rehabilitation of HIC
Respected sir/madam! Assalam-o-Alaikum
I, Hina Noor, Ph.D scholar of Foundation University is requesting hereby for
research grant. My topic of research approved by BASR is “Development and Validation
of Model of Aural Rehabilitation of Profound Hearing Impaired Children in Punjab- an
Experimental Study.” After development of the model, I am at the stage of its validation
through experimentation. The children of both experimental and control group of the
study need to wear bilateral digital hearing aids during experimental phase. Unfortunately
the survey of all government special education schools revealed the fact that no school
has 20-30 hearing impaired children possessing behind the ear digital hearing aids.
Without provision of hearing aids the intended experimental training and analysis of its
effects on the aural skill development of the children can be documented.
It is therefore humbly requested to please provide the hearing aids and its fitting
expenditure so that the stage of experimentation can begin without any further delay. The
results of the study will highlight the weaknesses present in the academic setup of these
children and are likely to bring drastic change in the lives of HIC. Other relevant
supportive documents are attached herewith.
Thanking you in anticipation. Yours truly,
HINA NOOR