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Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl

Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants Areti Okalidou a,b, Mariana Kitsona b, Flora Anagnostou b, Marinella Tsoukala b, Stella Santzakli b, Stamatia Gouda b, Thomas P. Nikolopoulos b,c,* a b c

University of Macedonia, Department of Educational and Social Policy, 156 Egnatias Street, P.O. Box 1591, Salonika 540 06, Greece Hearing Group, Panhellenic Association of Logopedists, El. Venizelou 50, Athens 155 61, Greece1 Athens University, Otolaryngology Department, Attiko University Hospital, Rimini 1, Athens 12462, Greece

A R T I C L E I N F O

A B S T R A C T

Article history: Received 2 December 2013 Received in revised form 30 March 2014 Accepted 1 April 2014 Available online xxx

Objectives: To assess the knowledge, experience and practices of speech and language therapists (SLTs) in Greece regarding children with cochlear implants. Methods: A special designed questionnaire was originally completed electronically by 313 SLTs via surveymonkey platform. Results: From the 313 respondents 35% had worked with implanted children, 37% received course training and 44% had participated in post-graduate seminars. Although 96% believe that there are differences in the management of these children, almost 47% of the participants did not have adequate knowledge on the candidacy criteria for implantation and 70% regarding the available technology for implanted children. Knowledge and skills on CI were better for those SLTs who worked with hearingimpairment. Diverse practice models were noted. Interestingly, more than 87% of the participants advocated toward further training and supervision in the field, even the ones who had less than extensive knowledge in working with CI. As for practice, a lack of organizational interdisciplinary structure became evident. Conclusions: There is a growing need for well organized professional training and team networks for SLTs in order for them to further improve their knowledge and service delivery to implanted children. ß 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Speech and language therapist Cochlear implant Rehabilitation Knowledge Education Logopedic

1. Introduction Over the past 20 years, cochlear implantation of children with severe to profound hearing loss has proven to be a very effective method of management for the development of oral language, especially in young implanted children [1–8]. Long before the development of cochlear implants, the focus on oral language, and furthermore the interdisciplinary type of intervention that was adopted for its development, have been attested choices, available for severely hearing-impaired or deaf children who wore hearing aids. Intervention was enacted via the professional collaboration of audiologists, speech-language pathologists and teachers of the deaf, much like it is today for children with cochlear implants [9]. The vital role of SLPs in the development of language of hearingimpaired children has been described by Carney and Moeller [10].

* Corresponding author at: Athens University, Otolaryngology Department, Attiko University Hospital, Rimini 1, Athens 12462, Greece. Tel.: +30 2105 831399. E-mail addresses: [email protected] (A. Okalidou), [email protected] (T.P. Nikolopoulos). 1 Tel.: +30 2107779901; [email protected], [email protected].

Evidently, the recent and ongoing, rapid advances of the cochlear implant technology along with the newborn screening procedures adopted worldwide [11] led to a new pediatric population in need for services, the generation of very young children who are born with severe to profound hearing loss but nevertheless are fitted early with powerful systems that aim to restore audition. This situation created new challenges for the medical, technological, (re)habilitation and educational sectors. The latter professionals, that is speech-language pathologists and educators were called to modify their approaches toward these hearing-impaired/deaf children, placing a greater emphasis on the development of listening skills and learning capacity via audition. The new demands for fostering the communication skills of children with CI were incorporated into national guidelines of the Ministry of Health [12] and other published manuscripts of clinical/educational joint committee working groups [13]. Speechlanguage pathologists also became aware that new methods are called for treating very young children due their young age and the developmental cognitive, auditory and communication schemata of the targeted population [14]. They had to keep abreast with the medical technology but also audiological monitoring at the

http://dx.doi.org/10.1016/j.ijporl.2014.04.001 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article in press as: A. Okalidou, et al., Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.001

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hospital, that is, the map fittings of implants and the whole auditory follow-up of CI children at the CI center. They had to establish routes of communication for troubleshooting and for monitoring auditory behavior in everyday settings, in school and in therapy. At later ages, educators receive these students mostly at mainstream settings and need to respond to their individual specific needs and communication schemes in the classroom as well as in special educational settings when children are late-fitted or face additional challenges in their development, such as multihandicap [15]. In addition, the integration in educational settings for school-aged children with cochlear implants called for the collaboration of speech-language pathologists and classroom teachers, on a consultation basis, to meet individual student needs. However, although highly specialized services are called for supporting CI children in early speech and language intervention and also in classroom, such training is not often offered in the curricular of studies in communication disorders, even in countries with highly qualified programs in the field [16]. Consequently, there is a scarcity of services by experienced SLTs, as indicated by the Joint Committee on Infant Hearing (JCIH) which pointed out to the shortage of pediatric audiologists, early interventionists, and SLPs [17]. On the other hand, an array of specialized continuing education programs and specialized organizations, such as Ear Foundation and AG Bell Association for the Deaf, try to serve this purpose by providing seminars and specialized training around the world. Very few studies in the literature have conducted surveys to investigate the knowledge and skills of SLTs regarding pediatric cochlear implantation [18,19]. Both these two surveys, although with 10 years difference, documented the relative lack of knowledge and skills of SLTs in managing children with cochlear implants and emphasized the need for specialized services. The aim of the present study was to assess the knowledge, experience, and practices of SLPs working with CI children. 2. Method 2.1. Subjects A specially designed questionnaire was addressed through surveymonkey to the members of the Panhellenic Association of Logopedists–Speech Therapists (P.A.L.), and the Association of Scientists of Speech Pathology–Speech Therapy of Greece (S.E.L.L.E.). P.A.L. was established in 1982 and its members have graduated from both old and recent SLT educational programs, mostly international. S.E.L.L.E. was established in 2002 and its members have graduated from more recent SLT programs, over the past 13 years. The questionnaire was returned back by 313 Greek SLTs. Since the questionnaire consisted of sections with different content items, the number of respondents who filled out each section varied from 96 to 313. 2.2. Material For the construction of the questionnaire, a pool of questions was originally selected from the Cochlear Americas Educator’s Guide to Cochlear Implants [20] and discussed to form a basis for raising issues and formulating the relevant questions by a professional group of 7 specialists. Only the questions reached by consensus by 1 ENT and 6 SLTs were finally selected to form the first version of the questionnaire. Subsequently, the questionnaire was distributed to three other SLTs who have been working with children with hearing loss and CI. They were asked to fill it out and highlight any questions that were formulated in an ambiguous manner. Furthermore, they were also asked to explain the way they understood some questions selected randomly and their

response options. Subsequently to this procedure, a couple of questions were reformulated. The questionnaire consisted of 25 items addressing the related to CI topics divided into three parts: (a) training and experience, (b) knowledge and professional views, and (c) current practices. The training and experience part consisted of 8 items in question format (Q1–Q8). The topics concerned the highest degree earned, the types of formal and informal training received with respect to CI and the clinical experience in working with CI children and their families. The response scale in this section varied from a binary choice (yes/no) to a 3-level scale concerning the education degrees earned and then to 4-level scale that prompted respondents to rank their experience and track the amount and course of continuing education regarding cochlear implantation. Indicatively, experience was ranked according to the number of years in working with hearing-impaired children, CI children, and families. In the remaining parts of the questionnaire, the respondents were asked to rate their knowledge and practices using a 4-level Likert scale (strongly agree to disagree). The part concerning knowledge and views consisted of 8 items (Q9–Q16) addressing areas of expertise such as candidacy criteria, technology, auditory training and views regarding the training approaches, use of sign language and need of further training. Finally, the last part consisted of 9 items (Q17–Q25), and was addressed only to those SLPs who have had working experience with CI children. It aimed to sample current practices concerning the collaboration with the CI teams, the parents and the school personnel, the auditory, speech and communication training, and the use of telepractice. The results were analyzed by calculating the percentage of responses obtained for each response option of every question/ item. The percentages were converted to proportions and series of Difference tests, two-sided, were computed in order to test the significance of differences between two proportions, via the software package STATISTICA version 9. Moreover, for the last two parts where an ordinal scale was used, i.e. the Likert scale, a weighted average score was generated based on all responses for a single item [21] in order to capture the central tendency of responses across the Likert-scale grading that corresponded to each item. The central tendency across items of a single category, e.g. Knowledge, were compared with each other in order to detect areas of low and high competence. In addition, the central tendencies of selected items were compared across categories, e.g. Knowledge versus Practice and subgroups (e.g. SLTs with experience in working with children with HA vs. CI) in order to draw further conclusions for needs assessment. 3. Results 3.1. Training and experience The various levels of education and training in SLT and CI, respectively, are presented in Figs. 1–3. The level of highest education in speech therapy of the respondents is depicted in Fig. 1. Out of 313 respondents, 70% percent had a bachelor degree in speech therapy whereas 30% had completed a post-graduate degree. Furthermore, a little more than one-third, 37%, received supervised, hands-on training in CI during their formal education studies (Fig. 2), whereas a greater number of professionals, 44%, chose to attend continuous education seminars or programs regarding CI (Fig. 3), especially within the last 5 years (38%) and also, kept abreast with the literature on CI (49.2%). Finally, regarding the SLTs’ clinical experience, out of 313 respondents, less than half, namely134, 42.8%, have worked with children with hearing loss. Although nearly half of them, i.e. 140,

Please cite this article in press as: A. Okalidou, et al., Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.001

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Highest Education Degree of SLT Respondents 2%

28% bachelor degree master's degree doctorate degree

70%

Fig. 1. Highest education degree of SLT respondents.

Practical training in CI during University/College

37%

Training No Training

63% Fig. 2. Practical training in cochlear implantation during university/college.

Continuous Education Training via Seminars/Programs in CI

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in their practice. From them, 30% of SLTs had post-graduate training, similar to the overall SLT sample. Interestingly, 15 of them, that is 50% reported that they had worked with children with CI in their practicum and 15, that is 50% attended seminars, mostly during the past 5 years (10 respondents, 33%). Over half of them, 19, 63%, kept abreast with the bibliography on cochlear implants. One hundred and eight SLTs have been working with children with CI. Forty-one SLTs had received a post-graduate degree, 38%, yielding a higher percentage as compared to the overall sample. Also, 67 respondents, that is 63% were trained in practicum and 83 respondents, i.e. 78% attended seminars after they graduated, mostly (70 respondents, 84%) over the past 5 years. To address any differences in education and training based on experience level, two groups of SLTs were compared, i.e. the ones who have been working with children with CI for 6 years or longer versus those who have been working with them over the past five years only. Over half of the experienced SLTs, 47 respondents, i.e. 60%, had received post-graduate training and 43 of them, i.e. 92% attended seminars mostly over the past five years (38 respondents, 81%). Among the less experienced SLTs, which were 60, only 14, i.e. 23% had received post-graduate training. The percentage is lower than the percentage found for the general sample of SLTs. Furthermore, 29 respondents, i.e. 48% had worked with children with cochlear implants in their practicum and 41 respondents, i.e. 68% attended seminars, mostly over the past 5 years (37 respondents, 90%). 3.2. Knowledge and professional views

44%

Yes No

56%

Fig. 3. Continuous education training via seminars/programs in cochlear implantation.

44.8%, have had a form of collaboration with families of children with CI, a smaller percentage of nearly one-third of the SLT respondents, i.e. 108, 34.5%, had been working with children with CI. Fig. 4 shows the clinical experience of SLTs with CI children, graded over the total number of years they had worked so far with CI children. As seen, a greater number of SLTs, 62, has been involved with CI (re)habilitation over the past five years. The education level and training on habilitation of cochlear implants of those who had been working with children with hearing loss have been further investigated. Thirty speech therapists have worked with hearing-impaired children who have been using hearing aids but had not worked with cochlear implants

Number of years in working with CI children

11%

4% not working with CI children working for 1-5 years

20%

working for 6-15 years 65%

working for >16 years

Fig. 4. Number of years working with cochlear implant children.

Table 1 presents the content of statements along with the percentages obtained for each response option in the Likert scale. The right end column lists the weighted average for each response along a 1–4 scale. Based on Difference tests for proportions, the significance level (a < .05) of the highest percentage in at least two pairwise comparisons within the same response set is marked with an asterisk (*). As seen in Table 1, for Q9, the majority of SLTs, 192 respondents, i.e. 78%, believed that there are either many or substantially enough (‘‘adequate’’) differences in speech/language therapy approach between hearing-impaired children with hearing aids and children with cochlear implants. The weighted average on the response set was 2.07, that is, it fell close to rank 2, ‘‘adequately agree’’, which yielded a significantly higher percentage (144 respondents, 58.5%, p < 0.001) among other responses. A separate analysis for the SLTs who have been working with children with hearing loss has been conducted. Table 2 lists the central tendencies of responses, as expressed by the weighted average on each response set for four subgroups drawn from the general sample of SLTs, (i) SLTs with prior experience in hearingimpairment (HI) but no experience in CI, (ii) SLTs with prior experience in CI, (iii) SLTs with less experience with CI (5 years) and (iv) SLTs with more experience with CI (6 years). Based on Table 2, the central tendencies were: (a) the SLTs with experience in hearing-impaired children but no experience in cochlear implants also believed that there are differences and responded with a weighted average on the response set of 1.86, close to rank 2 ‘‘adequately agree’’, and (b) the SLTs with prior experience in working with children with CI responded with a weighted average of 1.68, which fell between rank 1 (‘‘strongly agree’’) and 2 (‘‘adequately agree’’). The latter central tendency did not differ based on amount of experience with CI, i.e. less than five years as opposed to 6 years or longer. In Q10–12, SLTs indicated that they have less than adequate knowledge on basic aspects of cochlear implantation related to candidacy, technology and auditory training, respectively. Specifically, for Q10, the majority of SLTs, 162, 65.9% possessed either

Please cite this article in press as: A. Okalidou, et al., Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.001

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Table 1 Content of statements on knowledge and professional views and percentages for each response option. The asterisk (*) denotes that the highest percentage is statistically different (at a < .05), from at least two other percentages in the same response set, based on difference tests for proportions. Statement content

Strongly agree (1) (%)

Adequately agree (2) (%)

Less agree (3) (%)

Disagree (4) (%)

Weighted average

Q9. Differences in therapy among HI children with HA vs. CI Q10. I am familiar with candidacy criteria for pediatric CI Q11. I have knowledge on current CI technology Q12. I have knowledge on the hierarchy of listening skills Q13. Early therapy goals for CI include development of prosody and other pre-linguistic skills Q14. Use of sign language is detrimental to spoken language development in CI children–discourage Q15. Need for further knowledge and expertise to work with CI children Q16. Need for supervision in working with CI children

19.5 16.7 7.7 16.7 28.5

58.5* 36.2* 22.8 39.4 56.9*

17.5 29.7 41.5* 33.7 10.6

4.5 17.5 28.0 10.2 4.1

2.07 2.48 2.90 2.37 1.91

15.4

22.8

30.9

30.9

2.77

64.2*

22.8

10.2

2.8

1.52

56.9*

30.9

8.5

3.7

1.59

Table 2 Content of statements on knowledge and professional views and weighted averages for subgroups of SLTs with prior experience with hearing-impairment and/or cochlear implantation. Statement content

Experience with HI but not CI N = 30

Experience with CI N = 108

Less experience with CI (5 years) N = 47

More experience with CI (>5 years) N = 60

Q9. Differences in therapy among children with HA vs. CI Q10. I am familiar with candidacy criteria for pediatric CI Q11. I have knowledge on current CI technology Q12. I have knowledge on the hierarchy of listening skills Q13. Early therapy goals for CI include development of prosody and other pre-linguistic skills Q14. Use of sign language is detrimental to spoken language development in CI children–discourage Q15. Need for further knowledge and expertise to work with CI children Q16. Need for supervision in working with CI children

1.83 1.90 2.47 2.00 1.37

1.68 1.61 1.94 1.61 1.51

1.68 1.82 2.13 1.78 1.52

1.68 1.47 1.70 1.40 1.51

2.17

2.20

2.05

2.43

0.97

1.71

1.38

2.15

1.07

1.58

1.27

2.00

adequate (73 respondents, 36.2%) or little knowledge (89 respondents, 29.7%) on candidacy criteria for CI. The difference in percentages was not significant. The weighted average was 2.48, suggesting that SLTs have less than adequate knowledge on candidacy criteria. In Q11, the majority of SLTs, 171 respondents, i.e. 69.5%, declared either little (102 respondents) or no knowledge (69 respondents) on the technology of CI. The weighted average was 2.90 and it fell close to the third rank of ‘‘less agree’’. In Q12, the majority of SLTs, 180 respondents, that is 73.1%, had either adequate or little knowledge on building a hierarchy of listening skills during therapy with CI children. There was no significant difference among the highest percentages and the weighted average, 2.37, fell between adequate and little knowledge on this aspect of speech/language therapy for CI. The responses on Q10–12 for the ones that had been working with hearing loss indicated a graded improvement in knowledge on the above three aspects of CI. Specifically, for Q10 on knowledge of candidacy criteria for implantation, the responses of SLTs with prior experience in hearing-impairment but not CI yielded a weighted average 1.90, denoting adequate knowledge. The responses of SLTs with prior experience in CI yielded a weighted average 1.61, denoting a knowledge level between strong and adequate. Among the latter sample, the number of years of experience in working with CI yielded some differences in the expected direction, that is, the more experienced SLTs (with working experience of 6 years or longer) yielded a central tendency of 1.47 as opposed to the ones with less experience (up to 5 years) which was 1.82. In sum, the SLTs who have been working with hearing-impairment possessed adequate knowledge on candidacy criteria for CI which tended to be rated better than adequate based on prior experience with CI. For Q11, inquiring about knowledge of CI technology, the responses of SLTs with prior experience in hearing-impairment but not CI yielded a weighted average 2.47, denoting less than adequate

knowledge. The responses of SLTs with prior experience in CI yielded a weighted average 1.94, denoting adequate knowledge. Among the latter sample, the number of years of experience in working with CI yielded some differences in the expected direction, that is, the more experienced SLTs (with working experience of 6 years or longer) yielded a central tendency of 1.70 as opposed to the ones with less experience (up to 5 years) which was 2.13. In sum, for those SLTs with prior experience with hearing-impairment, the level of knowledge on current technology for children with CI fell in the adequate range or better, depending on CI experience. As for Q12 referring to knowledge of the developmental stages of listening skills, the responses of SLTs with prior experience in hearing-impairment but not CI yielded a weighted average of 2.00, denoting adequate knowledge. The responses of SLTs with prior experience in CI yielded a weighted average 1.61, denoting a knowledge level between strong and adequate. Among the latter sample, the number of years of experience in working with CI yielded some differences in the expected direction, that is, the more experienced SLTs (with working experience of 6 years or longer) yielded a central tendency of 1.40 as opposed to the ones with less experience (up to 5 years) which was 1.78. In sum, for those SLTs with prior experience with hearing-impairment, the level of knowledge on the developmental stages of listening skills fell in the adequate range or better, depending on CI experience. In Q13 and 14, SLT beliefs for early speech/language goals and the use of sign language in the speech/language therapy session with CI children were sampled. In Q13, the majority of therapists, 210 respondents, i.e. 85.4%, stated that early speech/language goals should include training in prosody and other prelinguistic skills. The highest percentage corresponding to 140 respondents, 56.9%, fell in the second rank (‘‘adequately agree’’) and was statistically significant compared to the other responses. Moreover, the weighted average, 1.91, fell close to the second rank, ‘‘adequately agree’’. In

Please cite this article in press as: A. Okalidou, et al., Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.001

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Q14, views were spread across all possible responses, as no percentage was statistically higher than the other ones. The majority of SLTs, 152 respondents, 61.8%, believed that sign language is either little or not at all detrimental for the speech/language development of children with CI. The weighted average was 2.77 and corresponded closer to rank 3, ‘‘less agree’’. A separate analysis for Q13 and Q14 for the SLTs working with hearing-impairment revealed some differences. For Q13 referring to therapeutic goals at the early stages of speech-language therapy, the responses of SLTs with prior experience in hearingimpairment but not CI yielded a weighted average of 1.37, denoting a strong-to-adequate agreement in working with prosody and other prelinguistic goals at the early therapy stage. The responses of SLTs with prior experience in CI were similar to the ones working with hearing-impairment, yielding a weighted average of 1.51. Among the latter sample, the number of years of experience in working with CI did not affect the above therapy choice. In sum, the SLTs with prior experience in hearingimpairment expressed stronger opinions than the general SLT sample toward setting up goals for prosody and other prelinguistic skills at the early stages of speech/language therapy. For Q14, stating that sign language is harmful to speech/language development of children with CI, the responses of SLTs with prior experience in hearing-impairment but not CI yielded a weighted average of 2.17, denoting that this group tended to ‘‘adequately agree’’ on the above statement. The responses of SLTs with prior experience in CI were similar, yielding a weighted average of 2.20. However, some variation in central tendency was noted since the more experienced clinicians with CI tended to disagree more with the statement on the potential harmfulness of sign language (weighted average 2.43) than the less experienced ones, who adequately agreed (weighted average 2.05). In sum, with respect to the potential harmfulness of sign language use with children with CI, the SLTs with prior experience with hearing-impairment and/or CI tended to adequately agree more as compared to the general sample; however, their beliefs varied based on their amount of working experience with CI. Finally in this section, Q15–16 examined the SLTs’ needs for further training and supervision. In Q15, a vast majority of SLTs, 214 respondents, 87%, expressed the need for further training on aspects of CI. The highest percentage corresponding to 158 respondents, 64.2% was obtained for the category ‘‘strongly agree’’ and was statistically significant. The weighted average, 1.52, fell between the first and second rank and validated the above finding. As for Q16, a similar pattern was observed with 216 respondents, i.e. 87.8% of respondents expressing the need for supervised clinical work for their CI clients. The highest percentage, 140 respondents, 56.9%, was obtained for the first rank ‘‘strongly agree’’ and was statistically significant. The weighted average, 1.59 fell between the first two ranks, and validated the general trend for supervised practice. Interestingly, similar views were obtained by the SLTs with prior experience with hearing-impairment and/or CI. More specifically regarding Q15 on the need for further training on CI, the SLTs with prior experience with hearing-impairment but not CI yielded a central tendency of .97, thereby strongly agreeing for the need for further training on audition, speech and language in working with children with CI. Responses of the SLTs with prior experience with CI fell close to the ones of the general sample, yielding a central tendency of 1.71. However, views deviated based on amount of working experience, that is, the more experienced clinicians yielded a central tendency of 2.15, just a little below ‘‘adequately agree’’, whereas the less experienced clinicians yielded a central tendency of 1.38, between ‘‘strongly agree’’ and ‘‘adequately agree’’. It appears that among the groups with experience with hearing-impairment, the SLTs with no CI experience expressed a greater need for specialized training as compared to the general sample or to those

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with working experience in CI. With respect to Q16, the need for supervision in working with children with CI, the SLTs with prior experience with hearing-impairment expressed similar or even stronger views toward their need for supervision as compared to the general sample. Specifically, the ones with prior experience with hearing-impairment but not CI yielded a central tendency of 1.07, very close to ‘‘strongly agree’’. The trend was lower for SLTs with prior experience with CI, 1.58, that is similar to that of the general sample. Some variation in response trends occurred as a function of amount of experience since the less experienced clinicians yielded a central tendency of 1.27 as opposed to 2.00 (‘‘adequately agree’’) for the more experienced ones. In sum, the group of SLTs with prior experience in hearing-impairment felt a stronger need for supervision in working with children with CI as compared to the general sample. Some deviation was noted for SLTs with extensive experience in working with CI (6 years or longer). Yet, even this group indicated that they adequately agree for the need for supervision in their case. In sum, SLTs seemed to believe that therapy delivery of children with CI is different from the traditional therapy used for hearingimpaired or deaf children who wear hearing aids. They felt that they lagged behind in knowledge related to the basic aspects of implantation, such as candidacy, technology and fostering the development of listening skills, however, such knowledge was ranked as adequate in the case of SLTs who had prior experience with CI and improved as a function of amount of working experience. Moreover, the SLTs would most likely incorporate the training of prosody and prelinguistic skills at the early stages of post-implantation therapy but at the same time they might use sign language. The use of sign language was less preferred among clinicians with working experience on hearing-impairment and/or CI but seemed to be an option for more experienced clinicians who have been working with CI children for a long time. Finally, the respondents stressed out the need for further training and supervised work in order to gain more expertise in assisting CI children for the development of spoken language. 3.3. Practices This section was addressed to those SLTs (N = 96) who have been working with CI children in their therapy practice. Table 3 presents the content of statements for SLT practices, Q17–25, along with the percentages obtained for each response option in the Likert scale, their significance and the weighted average. A series of statements, Q17, Q24–Q25, aimed to examine the collaboration between the SLT and other professionals who work with children with CI. In Q17, about one-third of SLTs had adequate (28 respondents, 29.2%) or little (33 respondents, 34.4%) collaboration with the ENT and audiology staff of the CI center. The weighted average was 2.51, indicating an overall less than adequate collaboration. Apparently, a better collaboration seems to take place between the SLT and special educators, in both preschool and primary education levels. In Q24, about one-third of SLTs had either a strong (33 respondents, 35.1%) or an adequate (29 respondents, 30.9%) collaboration with special educators that work with CI preschoolers in early intervention. The weighted average, 2.16, validated the trend toward an adequately good collaboration. In Q25, more than one-third of SLTs declared either a strong (34 respondents, 36.2%) or an adequate (35 respondents, 37.2%) collaboration with the school-based special educators. The weighted average, 2.02, suggested an adequate collaboration. In Q18, 65 respondents, 67.7% of SLTs felt that they understand the mapping procedure and they can play a role by providing useful input for the mapping of the child’s cochlear implant. The weighted average in this statement was 2.14, indicating adequate agreement with the above remark, a value that is higher than the

Please cite this article in press as: A. Okalidou, et al., Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.001

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Table 3 Content of statements on practices and percentages for each response option. The right end column lists the weighted average and the asterisk (*) denotes that the highest percentage is statistically different (at a < .05), from at least two other percentages in the same response set, based on difference tests for proportions. Statement content

Strongly agree (1) (%)

Adequately agree (2) (%)

Less agree (3) (%)

Disagree (4) (%)

Weighted average

Q17. I collaborate with ENTs/audiologists of the CI center Q18. I understand the mapping procedure and my contribution to it Q19. Competency in design and implementation of SLT programs for CI children Q20. Use of alternative-augmentative communication for CI children Q21. Use of telepractice Q22.Variation of frequency and length of therapy sessions based on CI child’s needs. Q23. Parent involvement in therapy program is important Q24. Collaboration with special educators for preschool CI children Q25. Collaboration with special educators for generalization of skills in school

18.8 26.0 26.3

29.2 41.7 42.1

34.4 25.0 27.4

17.7 7.3 4.2

2.51 2.14 2.10

25.8 1.1 54.3

32.3 3.2 34.0

20.4 9.6 8.5

21.5 86.2* 3.2

2.38 3.81 1.61

92.6* 35.1 36.2

7.4 30.9 37.2

0.0 17.0 14.9

0.0 17.0 11.7

1.07 2.16 2.02

one obtained on the question regarding the collaboration between the ENT/audiologists and the SLTs. Moreover, in Q19–Q23, certain practice schemes were examined. In Q19, the majority of SLTs, 65 respondents, 68.4%, felt strongly or adequately competent in designing and implementing specialized therapy programs for CI children, however, more than one-third seemed to lag behind on these skills. The weighted average was 2.10, suggesting an overall adequate level of skills. As seen in Q20, there was a wide distribution of different practices regarding the choice and the amount of alternative-augmentative communication utilized during therapy with CI children. The weighted average, 2.38, indicated that overall the trend to use alternative-augmentative communication is lower than adequate. In Q21, 81 respondents, thereby the highest percentage of SLTs, 86.2%, did not use telepractice at all with children with CI. The difference was statistically significant (p < 0.001). Moreover, the weighted average, 3.81 confirmed the trends toward no use of that practice application. In Q22, the vast majority of SLTs, 83 respondents, i.e. 88.3%, varied the frequency and length of speech therapy sessions of CI children based on their needs. The tendency, as revealed by the weighted average of 1.61 was between strong and adequate. Finally, as seen in Q23, the vast majority of SLTs valued parental involvement in the child’s therapy program and regarded parental participation as a crucial component. Eighty-eight respondents, that is the highest percentage of them, 92.6%, was obtained for the first rank of ‘‘strongly agree’’ and was statistically significant (p < 0.001). Moreover, 95 respondents, i.e. 100%, agreed that parental involvement was either very important or adequately important, yielding a weighted average of 1.07, closer to ‘‘strongly agree’’. In sum, practice schemes of SLTs in Greece with children with CI involve a less than adequate collaboration with the medical staff of CI centers despite their attested adequate skills to contribute to the fitting process of the cochlear implant. The practicing professionals in the field of CI felt that they have adequate skills for delivering therapy to children with CI. They design flexible schemes depending on the child’s needs for frequency and length of therapy sessions and furthermore may choose alternative-augmentative communication, although less often, to facilitate the development of communication and spoken language. However, the use of telepractice is not a preferred scheme at present. Moreover, they all valued parental involvement. 4. Discussion The aim of the present survey was to examine the experience, knowledge and professional practice of SLTs working in Greece with respect to children with cochlear implants. As indicated, there is a growing need for speech and language services for children with CI as more than one-third of SLT respondents have been working with implanted children, especially during the past five

years and more have been involved with family consultation visits. Although more than a third of them have received formal training and a greater percentage attended continuous education seminars, the majority of SLTs believe that implanted children need different, specialized services as compared to hearing-impaired children who use conventional hearing aids. This belief is consistent with the declared need for more training and supervision, revealed by the majority of SLT respondents in this survey. The above finding is on par with previous studies [18,19] who have also documented the limited knowledge and need for more training for SLPs in the U.S. Yet, in the study by Cosby [18], the majority of SLPs in the U.S. have graduate degrees (80.6%) in contrast with the findings for SLTs in our country who most of them have only undergraduate degrees. Also, more than half of the SLPs in the U.S. have worked with CI children (54.2%) whereas only about one-third of SLTs in Greece have done so. It is interesting to note that although 80.5% of SLPs [18] received no formal training regarding CI as opposed to 63% in the Greek sample, a greater percentage of them have been working with CI children. Finally, the results are in agreement with Cosby [18], where 60–85% of SLPs had reported limited knowledge in basic aspects of CI, such as CI candidacy, surgery, device components, CI function and troubleshooting. In the present study, SLT respondents reported less than adequate knowledge in similar areas, i.e. candidacy, technology and auditory skills with a CI. However, a greater percentage of Greek SLTs reported a greater readiness (68.4%) in improving the speech, language and auditory skills of CI children as compared to the Cosby [18] study (30–50%). Apart from the analysis of the general sample of SLTs, a separate analysis on training, knowledge and beliefs on CI was made by selecting subgroups of clinicians who had prior experience in working with children with hearing loss. The educational level of SLTs who have been working with children with hearing loss who wear conventional hearing aids was higher as compared to the general sample, as a greater percentage possessed a post-graduate degree and received informal (seminars) and formal training (practicum) on CI habilitation. Trends were also similar for SLTs with extensive experience in working with CI. However, the ones that have been working with children with CI for a period up to five years seemed to lag behind in the level of formal education but underwent through more informal training as compared to the general SLT sample. In view of the fact, that the pediatric population of children with CI is increasing and less experienced professionals are interested to gain expertise, as shown from their greater pursuit of informal training, there appears to be a need to offer these professionals more opportunities for advanced studies in the field of CI. In general, the SLTs who had been actively involved in working with children with hearing loss tended to have received training in this field in their practicum. Turning over to other aspects of this survey, the general sample of SLTs seemed to have less than adequate knowledge about the

Please cite this article in press as: A. Okalidou, et al., Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.001

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candidacy criteria for CI, the current CI technology and the building of hierarchical listening skills. Evidently, many of them work with other disabilities or disorders. Nevertheless, the above aspects of knowledge are necessary to be mastered by the SLTs who are planning to work with communication in the pediatric CI population [22] since they participate in interdiscilinary and transdisciplinary teams with audiologists and oftentimes come in contact with children with hearing loss and their families prior to CI. The above skills appeared to be improved in the subgroups of SLTs with prior experience with HI and or CI and more so varied based on the amount of experience. In all cases, knowledge with CI technology appeared to be lagging behind. Regarding further training and supervision, the majority of SLTs, even the ones working with children with hearing loss and/or CI, stated that they needed further training and supervision. The need was stronger declared by the SLTs who had been working with children with hearing loss and no prior experience with CI. Apparently, the CI technology and the repercussions for habilitation seem to be of great concern for this group. It was interesting to note that most SLTs in the general sample will not oppose to the use of sign language with CI children and several of them are opt to use alternative-augmentative communication systems in their practice. This contrasts with the respondents’ belief that therapy is different in CI children as opposed to hearingimpaired ones with hearing aids. It seems that SLTs are following principles of therapy that were originally applied for deaf children who traditionally need the support of non-verbal systems or sign language. The beliefs of the subgroup of SLTs who had been working with children with hearing loss were somewhat different from the general sample. They all supported even stronger the development of prosody and prelinguistic skills. In addition, they tended to discourage the use of sign language in the habilitation of children with CI. An exception was noted for the SLT group with extensive experience in working with CI which disagreed less with this option. Possibly, experienced clinicians have a variety of children with CI in their caseload, including some children that were fitted late. For that population such supplementary nonverbal methods or the continuation or parallel use of the existing language system (L1), i.e. sign language, may be deemed necessary for further communication development. Another group is that of multi-handicapped CI children which often need supplementary or alternative communication systems. Several studies e.g. [7, 25, 26] have argued that sign language is not a good choice for CI children who need to focus on audition to acquire spoken language. However, other studies did not find negative effects in the concurrent use of oral and sign language (TC) in language development of children with cochlear implants [27,28] and leave the choice to the growing communicator [29]. The fact that the SLT respondents of this survey use sign language but also target the development of prosody and other prelinguistic skills (such as babbling and vocal play) suggests that they adopt or believe that mixed methods of communication training can be called for in therapy, depending on the patient’s needs. Finally, this practice trend is on par with the recent integration of JCIH regarding rehabilitation [22] where one of the recommendations for early intervention providers is to accept the family’s preference for using the speech and language skills they have learned along with any other visual system, including sign language. Moreover, in goal 4 of JCIH [22], the use of AAC devices and strategies are highly recommended for D/HH children with additional disabilities. Alternatively, it is also possible that the questions were ambiguously formulated and therefore, it yielded variable responses. Speech and language services in our country are mostly offered on a private basis, therefore, there is no formal interdisciplinary network that will support the (re)habilitation work with CI children. As shown, SLTs have less than adequate collaboration with the medical team of CI centers but manage to work closer

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with the educational personnel in schools and even more so with the child’s parents. The lack of established collaborations between the medical specialists and the SLTs deprives the latter of gaining more hands-on expertise and rounded knowledge on important aspects of CI, such as candidacy, technology and auditory development post-implantation. In addition, there are fewer opportunities for other professionals, e.g. in the medical team, to take advantage of the SLT skills. Interestingly, the majority of SLTs (more than half) believed that they can provide input for the child’s mapping based on their weekly contact and communication work with the child. In conclusion, it appears that the training and expertise of SLTs regarding CI can be enriched not only via the organization of more seminars and professional training programs but also via their active involvement with interdisciplinary work with other specialists in the CI teams. There are ample models in this area, implemented in Europe and in the United States [22,23]; hence, both governmental authorities and professional organizations need to become more aware of such options, build longitudinal interdisciplinary network collaborations and take actions that will improve the quality of services offered to children with CI and their families at all respects. A certification for D/HH maybe a necessary future step in order to advance professional development and ensure quality of services. Moreover, it was interesting to find that telepractice is not implemented nearly at all despite the fact that Greece has many islands and traveling as well as other hazards hinder the regular provision of specialized speech/language services. Since parental involvement is very highly regarded among the respondents, there is a good chance that successful sessions can take place via telepractice. Special piloting programs need to be organized and implemented in order to examine whether this technology can lead benefits to those children with remote access to speech/language services. Finally, the findings of the present study need to be cautiously reviewed and replicated in the future since the number of respondents is relatively small, maybe due to heavy caseload and limited available free time. Nevertheless, the sample size in the present study exceeded the one used in the previous study [18] where the number SLP respondents was 227. In general, results were fairly consistent and could be accounted for by the level of education and expertise. Another point of caution is that the questionnaire was not validated and it is possible that some responses in this first investigation yielded unreliable findings due to content ambiguity. However, most results were consistent with expectations. In conclusion, the results of the present study suggest that the field of CI presents challenges even for those working in it. For those with less or no prior experience in working with CI there is a need for graduate and post-graduate specialized training on CIs, to be considered by SLT programs, professional associations and possibly CI companies. The education needs of SLTs evolved mostly around issues of candidacy, technology use and building auditory skills whereas they felt more comfortable with other aspects of speech and language training. Support systems need to be developed for the use of long-distance technologies to deliver services by working SLTs to CI children and their families who live in remote and difficult-to-access areas. Acknowledgments We would like to address special thanks to the Panhellenic Association of Logopedists and Speech Therapists and also to the Association of Scientists Speech-Language Pathologists and Speech Therapists of Greece for their support and participation in this study. Many thanks should also be addressed to BYTE COMPUTER ABEE www.byte.gr, Spyros Vyzantios, Apostolos Kapetanios and Sotiris Tripolitsiotis for assistance with the electronic adaptation of the questionnaire.

Please cite this article in press as: A. Okalidou, et al., Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.001

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Please cite this article in press as: A. Okalidou, et al., Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants, Int. J. Pediatr. Otorhinolaryngol. (2014), http://dx.doi.org/10.1016/j.ijporl.2014.04.001