The Volta Review - Alexander Graham Bell Association

Volume 111, Number 3 

Fall 2011 

ISSN 0042-8639 

The Volta Review 

Alexander Graham Bell Association 

for the Deaf and Hard of Hearing 

The 

Volta 

From Screening to Care: A Qualitative Analysis of the 

Parental Experiences Related to Screening and 

(Re)habilitation Care for Children with Congenital 

Deafness in Flanders, Belgium 299 

Stefan Hardonk, Ph.D.; Greetje Desnerck, Ph.D.; 

Gerrit Loots, Ph.D.; Liesbeth Matthijs, M.A.; 

Geert Van Hove, Ph.D.; Erwin Van Kerschaver, M.D., Ph.D.; 

Hanna Björg Sigurjónsdóttir, Ph.D.; 

Christophe Vanroelen, Ph.D.; and Fred Louckx, Ph.D. 

Parent and Teacher Perceptions of Transitioning Students 

from a Listening and Spoken Language School to the 

General Education Setting 325 

Natalie Rugg, Ph.D.; and Vicki Donne, Ed.D. 

Literature Reviews 353 

Ellen A. Rhoades, Ed.S., LSLS Cert. AVT 

Review

The Volta 

Review 

Volume 111, Number 3 

Fall 2011 

ISSN 0042-8639 

The Alexander Graham Bell Association for the Deaf and Hard of Hearing helps families, health 

care providers and education professionals understand childhood hearing loss and the importance of 

early diagnosis and intervention. Through advocacy, education, research and financial aid, AG Bell helps 

to ensure that every child and adult with hearing loss has the opportunity to listen, talk and thrive in 

mainstream society. With chapters located in the United States and a network of international affiliates, 

AG Bell supports its mission: Advocating Independence through Listening and Talking! 

297 

Editors’ Preface 

Joseph Smaldino, Ph.D.; and Kathryn L. Schmitz, Ph.D. 

Research 

299 From Screening to Care: A Qualitative Analysis of the Parental Experiences 

Related to Screening and (Re)habilitation Care for Children with Congenital 

Deafness in Flanders, Belgium 

Stefan Hardonk, Ph.D.; Greetje Desnerck, Ph.D.; Gerrit Loots, Ph.D.; 

Liesbeth Matthijs, M.A.; Geert Van Hove, Ph.D.; 

Erwin Van Kerschaver, M.D., Ph.D.; Hanna Björg Sigurjónsdóttir, Ph.D.; 


325 Parent and Teacher Perceptions of Transitioning Students from a Listening 

and Spoken Language School to the General Education Setting 


Commentary 

353 Literature Reviews 


Regular Features 

369 Information for Contributors to The Volta Review 

Permission to Copy: The Alexander Graham Bell Association for the Deaf and Hard of 

Hearing, as copyright owner of this journal, allows single copies of an article to be made for 

personal use. This consent does not extend to posting on Web sites or other kinds of copying, 

such as copying for general distribution, for advertising or promotional purposes, for creating 

new collective works of any type, or for resale without the express written permission of the 

publisher. For more information, contact AG Bell at 3417 Volta Place, NW, Washington, DC 

20007, email editor@agbell.org, or call (202) 337-5220 (voice) or (202) 337-5221 (TTY).

Editors’ Preface 

Joseph Smaldino, Ph.D., 

Editor 

Kathryn L. Schmitz, Ph.D., 

Senior Associate Editor 

This edition of The Volta Review features research exploring the role and 

perspective of parents regarding care for a child with hearing loss. First, 

“From Screening to Care: A Qualitative Analysis of the Parental Experiences 

Related to Screening and (Re)habilitation Care for Children with Congenital 

Deafness in Flanders, Belgium” is a study on parent perceptions regarding 

care after their child did not pass the newborn hearing screening test. The 

range of parental attitudes towards the professionals that they worked with 

and their opinions regarding care is extremely helpful in informing early 

intervention professionals on best practices once an infant or child is in their 

care. Second, “Parent and Teacher Perceptions of Transitioning Students from 

a Listening and Spoken Language School to the General Education Setting” 

is a look at the perceived readiness of a child with hearing loss to enter a 

mainstream school setting. The parent responses show that a wide variety of 

tools, including early orientation and ongoing support, are critical for students 

with hearing loss to succeed in a mainstream educational setting. 

The parent-professional dynamic is critical in securing language opportunities 

for children who are deaf or hard of hearing. By looking at parent 

perceptions, professionals can improve and adapt their practices to better 

serve the family as a whole. One of the ways that AG Bell is working to aid 

those conversations is by developing an online information resource called 

the Listening and Spoken Language Knowledge Center. This web-based 

information portal will be a go-to resource for information about listening 

and spoken language communication, and will foster ongoing conversations 

between parents and professionals. Continue to watch www.agbell.org for 

additional information. 

The final manuscript in this issue is an expanded version of “Literature 

Reviews.” This commentary discusses the proper way of formatting and 

conducting a literature review, and is expanded to include information on what 

makes a review problematic. The Volta Review has strived to be a publisher

for new authors and professionals in the field. With tools like this and others 

available at www.agbell.org/TheVoltaReview, we hope that you will find the 

right guidance for creating and submitting a manuscript for peer review. As 

always, please don’t hesitate to contribute to The Volta Review. 

Sincerely, 

Joseph Smaldino, Ph.D. 

Professor, Department of Communication Sciences 

Illinois State University 

jsmaldi@ilstu.edu 

Kathryn L. Schmitz, Ph.D. 

Chair, Department of Liberal Studies 

National Technical Institute for the Deaf/Rochester Institute of Technology 

kls4344@rit.edu 

298

The Volta Review, Volume 111(3), Fall 2011, 299–324 

From Screening to Care: 

A Qualitative Analysis of 

the Parental Experiences 

Related to Screening and 

(Re)habilitation Care for 

Children with Congenital 

Deafness in Flanders, Belgium 

Stefan Hardonk, Ph.D.; Greetje Desnerck, Ph.D.; Gerrit Loots, Ph.D.; 

Liesbeth Matthijs, M.A.; Geert Van Hove, Ph.D.; 

Erwin Van Kerschaver, M.D., Ph.D.; Hanna Björg Sigurjónsdóttir, Ph.D.; 


The objective of this study is to analyze parental perspectives concerning the use of 

(re)habilitation services after Universal Newborn Hearing Screening (UNHS). A 

qualitative study design was used involving children with moderate-to-profound 

Stefan Hardonk, Ph.D., is a researcher in the Department of Medical Sociology of Vrije 

Universiteit Brussel in Brussels, Belgium. Greetje Desnerck, Ph.D., is a senior researcher at 

Hogeschool West-Vlaanderen in Bruges, Belgium. Gerrit Loots, Ph.D., is a professor at the 

Centre for Interpersonal, Discursive and Narrative Studies (IDNS) in the Department of 

Clinical and Lifespan Psychology at Vrije Universiteit Brussel in Brussels, Belgium. Liesbeth 

Matthijs, M.A., is a researcher at IDNS in the Department of Clinical and Lifespan Psychology 

at Vrije Universiteit Brussel in Brussels, Belgium. Geert Van Hove, Ph.D., is a professor in the 

Department of Special Education at Ghent University in Ghent, Belgium. Erwin Van 

Kerschaver, M.D., Ph.D., is a scientific adviser at Kind en Gezin in Brussels, Belgium. Hanna 

Björg Sigurjónsdóttir, Ph.D., is associate professor at the Centre for Disability Studies at the 

University of Iceland in Reykjavík, Iceland. Christophe Vanroelen, Ph.D., is a professor in the 

Department of Sociology at Vrije Universiteit Brussel in Brussels, Belgium. Fred Louckx, 

Ph.D., is a professor, in the Department of Medical Sociology at Vrije Universiteit Brussel 

in Brussels, Belgium. Correspondence concerning this manuscript may be directed to 

Dr. Hardonk at stefan.hardonk@vub.ac.be. 

(Re)habilitation for Children who are Deaf 299

hearing loss who were born between 1999 and 2001 and who are registered in the 

UNHS program in Flanders, Belgium. Parents of these children were interviewed 

using a topic list and a chronological scheme to register meaningful events while 

using (re)habilitative services. Subsequently, thematic content analysis was applied 

to the transcripts of the interviews. Analysis found that differences exist in parental 

experiences and some parents who were referred directly from UNHS to an ear, nose, 

and throat department were left with feelings of uncertainty and anxiety, creating an 

obstacle in the care trajectory for their child. The parental perception of diagnosis/care 

was also a cause for delay. Parents considered educational support at home, after 

UNHS, important. Results indicate that implementation of a UNHS program is in 

itself insufficient to ensure early intervention, and that adequate support is needed 

during the early care trajectory to avoid delay and parental distress. 

Introduction 

When a child is diagnosed with a congenital hearing loss, parents are 

expected to take steps to obtain specialized care for their child, and professionals 

can support families in taking these steps. In the last decade of 

the 20th century, the context of early intervention care trajectories has 

changed drastically. 

First, testing procedures, such as automated auditory brain stem response 

(AABR), offer a very reliable way of screening young children for hearing 

loss. As a consequence, parents can be informed about their child’s hearing 

loss a few weeks after birth, allowing an early start to specialized care and 

the application of assistive technologies (if requested), such as hearing aids 

and cochlear implant (CIs) (Anderson et al., 2004). Second, in a number of 

regions in the world, government or privately run health care institutions 

have established universal newborn hearing screening (UNHS) programs 

based on reliable testing methods (Nelson, Bougatsos, & Nygren, 2008; 

Thompson et al., 2001), leading to widespread early detection of hearing loss 

in those regions. 

These aspects of early hearing loss identification offer new opportunities 

for the functional development of children who are deaf or hard of hearing 

(Nelson et al., 2008). At the same time, parents—who are often unfamiliar 

with hearing loss—are suddenly faced with many care-related questions 

shortly after the birth of their child, specifically the context of early 

(re)habilitation. Parents need to take important steps at the beginning of 

the child’s care trajectory, in which (re)habilitation care may be considered 

a key issue. 

In reviewing past scientific research on children who are deaf or hard of 

hearing, much attention has been given to functional outcomes of therapy 

with a focus on providing evidence for the effectiveness of CIs (e.g., Beadle 

et al., 2005; Declau, Boudewyns, Van den Ende, Peeters, & Van de Heyning, 

300 Hardonk, et al.

2008; Eisenberg et al., 2006), although some studies also point out the limitations 

of this technology (e.g., Geers, 2004; Marschark, Rhoten, & Fabich, 2007). 

Furthermore, research has provided evidence for successful implementation 

of UNHS programs (Kerschner, 2004; Nelson et al., 2008; Uilenburg, 

Kauffman-de Boer, van der Ploeg, Oudesluys-Murphy, & Verkerk, 2009), 

with attention given to issues of effectiveness in terms of early care intervention 

(e.g., Neumann et al., 2006) and financial considerations (Grill et al., 2006; 

Mezzano, Serra, & Calevo, 2009). 

Parental perspectives with regard to care has received much less attention. 

Some researchers have studied parental decision-making with regard to CIs 

(e.g. Hardonk et al., 2010a; Incesulu, Vural, & Erkam, 2003; Kluwin & Stewart, 

2000; Okubo, Takahashi, & Kai, 2008), and a coordinated research effort 

in the United Kingdom was aimed at parental experiences related to UNHS 

(Young & Andrews, 2001; Young & Tattersall, 2005, 2007). In contrast to the 

extensive research on UNHS programs, scientific literature provides only 

limited information about the way parents experience events and decisions 

related to care after UNHS. Fitzpatrick and her colleagues (2007) reported 

in their quantitative study that parents preferred services at a clinic close to 

their home, with a frequency limited to once a week, and with access to 

support from other parents. The UNHS program did not appear to have any 

effect on those parents’ preferences. These are valuable findings; however, 

because parental care preferences and the impact of the UNHS were measured 

using a standardized questionnaire consisting of hypothetical clinic 

scenarios, the results are limited to issues of preference and as a consequence 

reveal little of the actual care trajectories that follow from UNHS. In a similar 

quantitative study by Brown, Bakar, Rickards, and Griffin (2006), parents 

reported satisfaction with the services they had received and high levels of 

family functioning. Brown et al. also investigated the association between 

family functioning and the child’s language performance, but none was 

found. Also in this case, due to the design of this study, it does not reveal 

aspects of the care trajectory that were followed, and the role of parents and 

service providers in the trajectory. 

In a qualitative analysis of interviews with parents and care professionals/ 

educators about available (re)habilitation and school programs, McKellin 

(1995) focused on the role of communication and educational options. He 

introduced a “career” concept to describe the steps that families with a child 

who is deaf or hard of hearing take—an approach that was further elaborated 

in a recent trajectory-based study of early intervention (Hardonk et al., 

2010b). However, McKellin’s analysis did not take into account the relatively 

new context that is created by the implementation of UNHS and the widespread 

use of hearing technology. Storbeck and Pittman (2008) added a qualitative 

analysis to their quantitative evaluation of early intervention with one 

of their main conclusions being that most parents were referred to the early 

intervention program by care professionals at a hospital, but this was not 


done immediately after diagnosis creating a referral gap of 1 year. However, 

the researchers did not thoroughly examine parental perspective on decisions 

made in the early care trajectory to explain the delay. In addition, this study 

was not based on a context in which UNHS is fully operational. Finally, previous 

studies by Hardonk et al. (2010a, b) have demonstrated the importance 

of investigating parental experiences with regard to their child’s hearing loss. 

In sum, acquiring more insight into parents’ experiences between screening 

and care is an important challenge to research on hearing loss. 

The unique situation of Flanders, Belgium, provides an opportunity for 

an in-depth study of parental experiences. In 1998, Flanders, the Flemish 

region of Belgium, pioneered a highly effective and quasi population-covering 

UNHS program based on AABR testing (Van Kerschaver & Stappaerts, 2000, 

2001, 2003). The program is coordinated by the public children’s welfare 

organization Kind en Gezin and has a high ratio of coverage in the target 

population; between 1999–2001, the ratio of tested versus nontested newborn 

children was constantly above 90% (Van Kerschaver, Boudewyns, Stappaerts, 

Wuyts, & Van de Heyning, 2007). In addition, different early intervention 

services are widely available through ear, nose and throat (ENT) departments 

in hospitals, (re)habilitation centers, and for educational support at home. 

ENT departments focus on diagnosis, audiological care, and hearing technology. 

(Re)habilitation centers provide some further diagnosis as well as outpatient 

multidisciplinary care, fitting of hearing aids (Hardonk et al., 2010b), 

and support in administrative procedures. Finally, services for educational 

support at home—which are mostly connected to a (re)habilitation center— 

aim at providing support in day-to-day parenting. All services are covered by 

Belgian Public Health Insurance and the parents’ own financial contribution is 

limited. For example, CI surgeries are fully covered, and parents are not 

charged more than 2 EUR (approximately $2.37 USD) per session for multidisciplinary 

(re)habilitation. In addition, families with low incomes are 

exempt from this charge. 

Given the current information available from empirical literature and the 

opportunities found in the Flemish context, a research project was initiated to 

investigate events in the early care trajectory after UNHS. This study is part of 

that research project, which is based on two important principles. First, the 

analysis is focused on the experiences of parents in care-related decision 

making and their interaction with professionals in matters of referral and 

provision of care-related support. Although research has often been based 

on a clinical and service-based approach to a child who is deaf or hard of 

hearing, valuable insights can be generated by studies that emphasize the role 

of the family in matters of a disability. Hearing loss is experienced not only by 

the child, but by all family members (Fisher & Goodley, 2007; McKellin, 1995). 

More specifically, parents participate in diagnosis, care-related decisionmaking, 

therapy, and education. Therefore, they should be considered as an 

active party involved in their child’s disability who can offer information on 

302 Hardonk, et al.

their experiences that is valuable to scientific research and professional 

practice (Lang, 2003). 

Second, the study uses the care trajectory concept as a base for data collection 

and analysis. To enable an analysis of parental experiences during the 

different care-related steps taken after UNHS, care-related events are ordered 

within a chronological trajectory framework. The care trajectory used in this 

study builds on the work by Strauss, Fagerhaugh, Suczek, and Wiener (1997) 

in which the care trajectory is defined as a multidimensional sequence of carerelated 

events. In our conceptual approach, three dimensions are used: the 

first dimension refers to care-events and decisions regarding the use of care; 

the second dimension represents the evolution of the child’s functional status 

related to the hearing loss; and the third dimension reflects the parental 

experiences related to the care trajectory. Events at the level of the first two 

dimensions induce different experiences, perceptions, and emotions, which 

in turn can have an effect on care-related decisions, parenting, and parental 

well-being. The results of this study focus on the third dimension, parental 

experiences related to the care trajectory. 

Aim of the Study 

The central aim of this study was to analyze the parental perspective with 

regard to the use of (re)habilitation services after UNHS. The character and 

timing of decisions and experiences related to the initiation and further use of 

multidisciplinary (re)habilitation care are analyzed within an early care trajectory 

framework. In-depth qualitative analysis was aimed at uncovering 

how the care trajectory follows after UNHS, and how parents experience 

care-related decisions, with much attention given to the interactions of parents 

with care professionals. Given these specific aims, the analysis does not 

extend to outcomes of care. That issue will be addressed in future research. 

Background Information on UNHS Procedures, ENT Departments, and 

Multidisciplinary (Re)habilitation Services 

For a better understanding of the results, some further information on 

UNHS and early intervention services is necessary. According to the official 

screening protocol in Flanders, when AABR testing indicates a possible hearing 

loss parents should be referred to a certified referral center for further 

diagnosis and (re)habilitation care. Moreover, the guidelines require that an 

appointment with the referral center be made immediately by the UNHS 

program nurse or doctor. The protocol includes administrative follow-up of 

the referral by a so-called “UNHS coordinator” (Van Kerschaver et al., 2007). 

In Flanders, 22 referral centers were certified by Kind en Gezin—the official 

authority in this matter. Of these, 12 are (re)habilitation centers and 10 are 

ENT departments in hospitals (Van Kerschaver & Stappaerts, 2000). 


The (re)habilitation centers provide further diagnosis as well as multidisciplinary 

care, including listening and spoken language therapy, sensorymotor 

therapy, psychosocial and administrative support, and fitting of 

traditional hearing aids and other devices. As far as diagnosis is concerned, 

an audiology department is located within the center and staff also refer 

families to ENT departments for diagnostic interventions requiring specific 

expertise or equipment—e.g. brainstem evoked response audiometry (BERA). 

Multidisciplinary (re)habilitation care is available through outpatient services 

and at home. Outpatient care is defined as the therapy provided by professionals 

at the (re)habilitation center and aimed at children who reside at home 

and visit the center for each therapy session. 

Methods 

Study Design and Data Collection 

This study used a qualitative design, based on a descriptive analysis of 

interviews with parents of a population of children in Flanders, Belgium, 

who have a congenital hearing loss and who do not have additional 

disabilities (Hardonk et al., 2010c). There were also two additional inclusion 

criteria. 

First, because the analysis was focused on social factors and the parental 

experiences related to the care process itself, we were attentive to possible 

interference by biomedical elements shaping the care trajectory. Therefore the 

research population was selected based on three clearly defined categories of 

hearing loss: 41–70 dB (moderate loss); 71–90 dB (severe loss); and > 90 dB 

(profound loss). Within these categories, children were included with all 

types of hearing assistive technology as well as children who use no such 

technology at all. 

Second, a specific age-interval was defined as an inclusion criterion. Initially, 

due to the fact that, for data collection, parents were asked to recall past events 

and experiences, only families with children ages 5 and over at the time of the 

interview (thus born before 2001) were included to allow for the analysis 

of sufficiently long postscreening care trajectories. This was necessary not only 

for this study, but for other studies that were part of this research project and 

using the same data. Later, based on the aim of our study, the upper age limit 

at the time of interview was set to 7 years to coincide with the fact that the 

Flemish UNHS program was first implemented in 1999 (Van Kerschaver et al., 

2007). By using trajectory durations of between 5 and 7 years, all fundamental 

early care-related events were included in the data. 

Participants were recruited based on the clinical and sociodemographic 

information gathered by the Flemish UNHS program. Their database— 

considering the program’s success—accounts for over 90% of the population 

of children with a congenital hearing loss in Flanders (Van Kerschaver & 

304 Hardonk, et al.

Stappaerts, 2000, 2001, 2003; Van Kerschaver et al., 2007). The population 

corresponding to the inclusion criteria was relatively small—only 69 children 

met the criteria due to the low prevalence of congenital hearing loss 

(Mehl & Thomson, 2002). Therefore, parents of all 69 children were 

contacted in the first wave of recruitment. To respect their privacy, all 

families were contacted personally by the organization responsible for the 

UNHS program and database (“Kind en Gezin”). Upon parental approval, 

the researchers were allowed to contact the collaborating families directly. 

Collaboration with Kind en Gezin was approved by the organization’s 

scientific committee and based on its research protocol. Families who had 

not responded were contacted again in a second wave of recruitment 

3 months later, from which point purposive sampling (Bunne, 1999; Patton, 

2002) based on UNHS data was applied in order to achieve a maximum of 

social diversity in the participating families (Arber, 2001). The relevance of 

purposive sampling criteria was assessed through a study of the literature 

and interviews with experts. The selected criteria of differentiation were 

province of residence, ethnicity, and poverty. For the latter criterion, the 

Child and Family Poverty Index present in the UNHS database was used. It 

is based on six indicators: household income, parental educational level, 

professional activity, parental intellectual stimulation of children, housing, 

and health. The two recruitment waves resulted in the participation of 

16 families; in one family, 2 children were included in the sample for a total 

of 17 children. Table 1 provides an overview of the main characteristics of 

the sample. 

Two in-depth, semistructured qualitative interviews were conducted with 

the participating families (Miller & Glassner, 2004). At the onset of the 

interview, parents were asked to tell about their experiences with regard 

to screening, and referral for diagnosis and (re)habilitation care. From then 

on, the interviewers used a checklist of relevant topics based on the literature 

and several expert interviews to ask the parents to go into further 

detail about experiences and decisions regarding care trajectory (Silverman, 

1993). Examples of topics include interactions with care professionals who 

referred the parents, content of referral messages, barriers experienced in 

following up on referral, and first encounters with professionals in early 

intervention services. 

The risk of gaps or inconsistencies in parents’ memories about events that 

had taken place 5–7 years prior to the time of the interview was an important 

concern in the development of the study design. Moreover, parents were not 

expected to merely recall general ideas or feelings about the care trajectory, 

but instead were asked to recall details related to their experiences. Therefore, 

in the qualitative data collection phase, the life grid method was implemented 

(Hardonk et al., 2010c). The life grid method involves the use of a chronological 

scheme in which the onset and ending of care-related events are 

registered during the interview. (An example is provided in Appendix A.) 


Table 1. Characteristics of research population and respondents 

Families contacted: 

First announcement 69 

Reminder 23 

Respondents (families): 

After first announcement 15 

After reminder 1 

Parent(s) participating in interview: 

Mother 10 

Father 0 

Mother and Father 6 

Hearing characteristics of parents: 

Moderate-to-profound hearing loss 0 

No hearing loss 22 

Total number of children included in research population: 17 

Included children per family: 

1 15 

2 1 

Gender of child: 

Male 8 

Female 9 

Age of child at time of interview: 

5 1 

6 9 

7 7 

Hearing loss of child: 

Moderate (41 – 70 dB) 4 

Severe (71 – 90 dB) 2 

Profound (> 90 dB) 11 

Type of hearing technology: 

Bilateral cochlear implants 6 

Unilateral cochlear implant and unilateral hearing aid 3 

Bilateral hearing aids 8 

Poverty: 

Yes 1 

No 16 

Province of domicile: 

Antwerpen 4 

Limburg 1 

East-Flanders 6 

West-Flanders 2 

Flemish-Brabant 4 

306 Hardonk, et al.

For this data collection, four grids were used to register different potentially 

relevant aspects of life: “care for the child,” “child’s education,” “parents’ 

occupational activities,” and “family and the home.” Each column of the grid 

represents 1 year between birth and the time of interview, and the rows are 

labelled to represent different types of care-related events, for example “screening” 

or “diagnostic activities at the ENT department.” Events reported by 

respondents during the interview were registered into a cell according to the 

aspect of life, the type of event, and the date when it occurred. Additional 

information was also registered in the grids, such as emotional responses, 

motives, aspects of progress or reduction in the child’s hearing loss, names 

of care professionals, advice received, etc. This was done for each interview 

for every care-related event reported by the parents. Structuring substantial 

amounts of care-related information through the use of the life grid method 

supported the interviewers and the participants at the time of interview 

because it allowed for cross-referencing, double-checking, and asking additional 

questions. Moreover, it was useful during analysis for quick data 

referencing (Hardonk et al., 2010c). Two researchers were present during 

each interview, one leading the conversation and the other registering information 

in the life grid and supporting the first interviewer. All interviews 

were recorded with a digital audio recorder, and the check list and life grid 

were in full view during the interview. 

The above described research protocol was approved by the “UZ Brussel” 

University Hospital Ethical Committee (reference 2006/139). 

Analysis 

Thematic content analysis was conducted within the framework of a phenomenological 

approach. The nature of the study objectives led to a qualitative 

design. The phenomenological approach lends to understanding the 

parents’ experiences and offers insight into how they attach meaning to the 

phenomena they experienced throughout the care trajectory. The approach is 

respectful of the way an individual perceives reality within a given context, 

and it can show both similarities and differences between the experiences of 

different families. Within this approach, the thematic content analysis was 

used to identify relevant themes and subthemes in the experiences and 

decisions of the families. All parental interviews were transcribed verbatim 

for analysis, to increase the reliability of the study (Silverman, 1993). 

After the first round of interviews, an observer triangulation procedure was 

implemented based on open coding (i.e., labelling text fragments with codes 

that reflect aspects reported by respondents as meaningful events or experiences 

in the care trajectory) (Lewins, 2001). The initial set of codes was based 

on the topic list used for the interviews, and new relevant codes were added 

in the course of the open coding process whenever new topics emerged 

(Fielding, 2001). Text fragments containing information on more than one 


topic were given multiple codes. Both interviewers participated in the 

observer triangulation procedure, in which consensus was pursued with 

respect to the coding through discussion of each interviewer’s codes. In 

addition, these discussions were supported by the life grid. 

The observer triangulation procedure resulted in a coding scheme that was 

used as a check list, revealing gaps in the interviews of the first round. This 

inspired the topic list for the second round of interviews, which were aimed 

at clarifying aspects of the parents’ accounts and filling gaps in the collected 

information. This approach resulted in a high degree of saturation with 

respect to the content, which means that all categories pertaining to the 

matter—which is delimited by the study aim and reflected in the topic list— 

were accounted for and little new information was acquired from the last 

interview (Arber, 2001; Green & Thorogood, 2004). 

After data collection, the coding scheme was used to label all interview 

transcripts. This scheme was conceived as a logical tree of codes, representing 

different topics found in the interviews. Different hierarchical levels represented 

main topics and subset topics, with all first-level codes containing at 

least one subset of codes that covered different aspects of the higher level 

codes. The coding scheme was further adapted in the process, based on 

substantial input by researchers and members of the interdisciplinary steering 

committee of the project. 

Based on the labels, the relevant text fragments necessary for thematic 

content analysis were collected through automated coded text queries. Additionally, 

contextual information for the selected text fragments was collected 

through systematic inclusion of surrounding text. The life grid also 

played a supporting role in this phase of analysis. Finally, all acquired 

information was classified, further labeled, and interpreted into the themes 

that are presented in the results section of this manuscript. All labeling and 

querying was done using NVivo7Ò software (QSR, 2006) for qualitative 

data management. 

It should be emphasized that the parental perspective on the care trajectory 

is the basis for this descriptive analysis. Information on the inclusion criteria 

and the purposive sampling criteria was neither part of the analysis nor 

the interpretation of the findings, unless the parents themselves reported on 

such causal relationships. 

Results 

The results are based on an analytical scheme of the different trajectories 

that were found in the parents’ accounts. From our analysis it appeared that 

their experiences and care-related decision making were centered on the connection 

between key events in the trajectories from UNHS to (re)habilitation 

care. These steps, which are important with regard to progression, obstacles, 

and delays in the trajectory, are represented in Figure 1 by the letters A-H. 

308 Hardonk, et al.

UNHS = Universal Newborn Hearing Screening; ENT = Ear, nose, and throat hospital 

department; MDRC = multidisciplinary (re)habilitation center; A. Referral to ENT departments 

and (re)habilitation centers; B. Referral from ENT departments to (re)habilitation centers; C. 

Parents’ own initiatives; D. Delay between UNHS and initiation of multidisciplinary (re) 

habilitation care; E. Changes in the use of outpatient multidisciplinary (re)habilitation services; 

F. End of outpatient multidisciplinary (re)habilitation care; G. Referral to educational support at 

home; H. End of educational support at home 

Figure 1. 

Schematic representation of key events in (re)habilitation care after UNHS 

An in-depth report is presented within each paragraph on parental experiences 

related to each step. 

The Trajectory to Outpatient (Re)habilitation Care 

Initiation of Further Diagnosis: Referral to ENT Departments and/or 

(Re)habilitation Centers 

All families were referred to one of the certified referral centers by the UNHS 

program’s nurse or doctor, with the exception of one family who was referred to 

a pediatrician near their home who is not a certified partner of the UNHS 

program. Some differences exist among the 15 families of the 16 children who 

were referred to a certified referral center. Nine families reported that they were 

referred to an ENT department and 1 family was offered the choice of a (re) 

habilitation center or an ENT department, a choice that they felt was difficult 

to make because they were unfamiliar with the differences between these 

services. The 5 families of the remaining 6 children reported that they were 

referred to a multidisciplinary (re)habilitation center, a type of service that most 

parents had little knowledge of and experience with. For 1 family, referral was 


aimed at a service providing educational support at home, where they were told 

that it was necessary to go to the outpatient care department first. These parents 

interpreted the initial referral to educational support at home as an unnecessary 

step in a period already characterized by uncertainty. 

When determining which service to attend, many parents reported that the 

UNHS program’s nurse or doctor referred them to a center based on their 

place of residence. However, 1 family was offered the choice of more than one 

center, which the parents reported as a difficult decision to make. Two families 

were referred to a certified center that was further away from their place 

of residence. These parents reported that the advice given by the referring 

doctor was based upon personal opinion of the quality of care at the centers. 

Making first appointments appeared to be an important issue in referral, 

because it could create obstacles in the care trajectory. For most families who 

were referred to a specific service, the UNHS program’s nurse or doctor made 

the first appointment. Four families made appointments themselves and most 

of these parents experienced making these appointments as an unnecessary 

obstacle. In one case, the parents simply received the full list of 23 certified 

referral centers with verbal instruction that they should choose one and then 

make an appointment. However, 1 family valued their own initiative in 

making appointments. After screening, these parents immediately contacted a 

family relative who is a doctor because they believed that he was in the best 

position to tell them which center offered the highest quality of care. 

For another family, support provided by the UNHS program staff extended 

beyond making appointments. The UNHS program’s nurse accompanied one 

mother on the first appointment at the (re)habilitation center. The mother 

explained that she needed support after referral because her husband rejected 

the test results and considered the suggestion of hearing loss to be a “shame 

on the family.” Moreover, she felt incompetent to act upon the referral and 

faced transportation problems. 

Initiation of (Re)habilitation Care: Referral from ENT Departments to 

(Re)habilitation Centers 

Nine families were initially referred by the UNHS program nurse or doctor 

to an ENT department in a general or university hospital. Because the services 

of an ENT department are focused on refined diagnostics, all families 

were subsequently referred to a (re)habilitation center for further multidisciplinary 

care. Seven families were referred based on the travelling distance 

from their home. One family received information from their ENT 

specialist that two centers offered the highest quality in care. This family 

reported that they experienced difficulty in making a choice for a service 

they were unfamiliar with. The parents ultimately relied on a recommendation 

for one center from another family who had experience with hearing 

loss, on fear of language barriers in one center situated in the bilingual 

310 Hardonk, et al.

Dutch-French Brussels Region, and on their expectations concerning travel 

time. Another family reported that the ENT specialist referred the family to 

a center that was further from their home than any other referral center 

because he was mistaken about their place of residence. Although it did not 

make complete sense, the family followed the referral because they considered 

the ENT specialist most competent to make that decision. 

Making appointments for (re)habilitation centers was found to be a problematic 

experiences for parents who were referred from ENT departments. Most 

parents reported that professional advice at the time of referral was limited to 

the issue of which (re)habilitation center the parents should contact, and only a 

few families received detailed contact information. With one exception, ENT 

specialists did not make the appointment but instead left this to the parents. 

As a result, parents reported strong feelings of confusion and uncertainty after 

their consultation at the ENT department. One mother recalled that the ENT 

specialist had advised her and her husband to contact a local (re)habilitation 

center because their child needed “(re)habilitation.” However, when the parents 

discussed the consultation later, it became clear that neither of them had 

actually understood what was meant by the “need for (re)habilitation.” Moreover, 

they had neither clearly understood the name of the (re)habilitation 

center and no consultation report was provided. The mother reported that 

she and her husband left the ENT department with no understanding of how 

to proceed. Shortly afterwards, they visited the local children’s welfare clinic 

where the UNHS program’s nurse provided an explanation as to why they 

should contact a (re)habilitation center, and which center was closest to their 

home. In response, the mother looked up the contact information of the center 

and made an appointment. These experiences indicate the importance of 

active counseling as minor misunderstandings can have important consequences 

in terms of parental well-being and delay in intervention. 

Initiation of Further Diagnosis and (Re)habilitation Care: Parents’ 

Own Initiatives 

The analysis shows that a second connection from UNHS to further diagnosis 

and (re)habilitation care exists, besides initiative shown from professionals. 

Three families quickly took matters in their own hands after UNHS indicated a 

possible hearing loss. They immediately took the next step in the care trajectory 

regardless of the referral by the UNHS program’s nurse or doctor. These parents’ 

confidence in taking necessary initiatives is explained by the fact that they 

had an older child with a hearing loss and, as a result, were familiar with 

screening, diagnosis, and care. One mother explicitly told the UNHS nurse that 

she did not expect any further action and that she and her husband would make 

all necessary arrangements. Another mother reported that she was more familiar 

with hearing loss than the UNHS nurse and more competent in making decisions 

regarding her child’s care trajectory. Two of these 3 families immediately 


made an appointment with the ENT specialist who had performed BERA on 

their older child because they wanted “to be sure” as quickly as possible that the 

younger child had hearing loss. For the third family, the mother believed that it 

was most appropriate to take her newborn with her to her older son’s next 

auditory-verbal therapy session at the (re)habilitation center. 

Delay Between UNHS and Initiation of Multidisciplinary 

(Re)habilitation Care 

Delay of early intervention services is an important issue, which, in this analysis, 

appeared to be connected to the parents’ experiences and perceptions. 

Although all families were referred to specialized care by the UNHS program’s 

nurse or doctor, for 3 families this did not immediately lead to further diagnosis 

and the initiation of care. One family reported that they had refused to let their 

child undergo further testing because the sedation required for BERA testing 

induced feelings of anxiety as they associated it with serious medical procedures. 

They concluded that “a possible hearing loss” was not important enough 

to take such measures on their newborn child. Because the ENT specialist had to 

conduct BERA without sedation, the procedure failed to yield reliable information. 

Subsequently, the parents were told by care professionals at the (re)habilitation 

center that nothing more could be done and to wait and see whether or 

not the child showed signs of hearing loss. The parents did not undertake any 

further action towards diagnosis/care until 2 1/2 years later when a speechlanguage 

pathologist connected to the child’s school suspected that the child 

may have a hearing loss. The speech-language pathologist referred the parents 

to an ENT specialist who advised the use of BERA once more. The parents 

reported that they were still uncomfortable about the fact that their child would 

be put under sedation, but on the other hand they had become worried about a 

possible hearing loss. They decided to move forward with the test, which 

showed a profound hearing loss. Shortly afterwards, they asked the (re)habilitation 

center to initiate further care. The parents’ reluctance to have their child 

subjected to sedation for the initial BERA test and the related professional 

response resulted in a 2 1/2 year delay to the start of the care trajectory. 

Another family that was referred to a (re)habilitation center decided to 

withdraw shortly after admission. This is the family in which the father put 

pressure on the mother to abandon care, as he felt that it implied acceptance 

of the diagnosis and the condition. Two years later, when their second child 

faced a similar test result, the mother was more determined that action 

should be taken towards care. She received much support from the UNHS 

nurse to make an appointment for both children, leading to the initiation of 

care. The father’s emotional response to the suggestion of possible hearing 

loss caused a 2 year delay to the start of the care trajectory. 

A third family followed referral to an ENT department, but BERA did not 

yield any indication of hearing loss. The parents were told by the ENT 

312 Hardonk, et al.

specialist that no further action was therefore required and they reported 

that although it appeared strange to them, they followed this advice. With 

the passing of time, through interaction problems with their child, they 

became increasingly suspicious of a possible hearing loss. Consequently, they 

made an appointment at the same hospital for a new BERA test, which 

revealed a severe hearing loss. The ENT specialist then referred the parents 

to a (re)habilitation center and care was initiated immediately after a delay 

of more than 2 years. The parents repeatedly expressed their disbelief at the 

first BERA results and to them it remained difficult to understand why a test 

procedure, which is presented as “highly reliable,” can be a major cause for 

delay in the initiation of care due to false negative results. 

These experiences indicate that aspects of testing care professionals consider 

routine practice could be a cause for delay because parents are not 

familiar with hearing loss and their perception is not based uniquely on 

clinical facts, but also on social and cultural aspects. This also plays a role in 

case of false negative test results; parents have strong faith in highly technological 

equipment operated by skilled medical professionals, causing them to 

trust test results over their own observations that indicate a possible hearing 

loss. This could cause delay when no active follow-up is provided. 

Changes in the Use of Outpatient Multidisciplinary 

(Re)habilitation Services 

Nine families who were referred to specialized care by health care professionals 

made one or more decisions that resulted in the initiation of care 

use at a different (re)habilitation center. This provides insight into the way 

parents experience and evaluate care. Six families reported that they perceived 

the travelling time to the center as a heavy burden for the whole family 

and therefore they decided to move to a center closer to their home or easier 

to access. For another family, the center’s opening hours were incompatible 

with parents’ working hours, which they experienced as a major obstacle 

to care use. 

Advice from care professionals was also reported as a cause for a change 

to another (re)habilitation center. At the first (re)habilitation center, 1 family 

was advised by care professionals to consult an ENT specialist for further 

diagnosis. Apparently, the ENT specialist was not aware of the fact that the 

child was already receiving (re)habilitation care and after further diagnosis 

referred the parents to a different (re)habilitation center further away from 

their home. They followed his advice because they valued his competence. 

Assumptions of peers about the quality of therapy and support for both child and 

parents were another motivation for parents to change centers. One family 

reported such a change after 3 months of therapy. 

The availability of educational support at home was at the basis of 1 family’s 

decision to start using care at another (re)habilitation center. The parents 


emphasized their need for educational support at home, which was unavailable 

at the first center. 

Finally, the rejection of the diagnosis and the necessity of any specialized care 

found in 1 family’s response reappears as an important element. After a 2 year 

delay and when their second child was born, the UNHS nurse contacted 

a larger (re)habilitation center and accompanied the mother during the 

assessment on admission and all subsequent therapy sessions. The mother 

stated that she had the impression that the larger (re)habilitation center 

had more expertise in intervention for newborn children than the first center 

that she had attended. 

The onset of infant school at one of the “Medical and Educational Services 

for the Deaf ” (MED) clusters was a decisive factor for 2 families’ who reported 

a second change of (re)habilitation centers. The parents explained their decision 

by the practical advantage of the concentration of all necessary services in the 

MED clusters. 

It appears from parental accounts that both practical factors (travelling 

distance and time, correspondence with special education facilities, or opening 

hours) and social factors (professional advice, social relations with peers, 

or information-seeking by parents) had an influence on their decision to 

change centers for outpatient (re)habilitation care. 

End of Outpatient Multidisciplinary (Re)habilitation Care 

Ending the use of (re)habilitation services is an issue for which little 

is known, even though it is a key component in a child’s care trajectory. This 

analysis shows that all parents took matters regarding the end of care very 

seriously because they reported responsibility, not only for the child’s wellbeing 

at a certain point in time but also for the child’s long-term development. 

Different experiences were reported in which the interaction with care professionals 

clearly plays a major role. All parents reported (re)habilitation care 

trajectories of more than 6 years at the time of interview. Most parents had not 

considered ending the use of outpatient care; they reported it was necessary 

and useful for their child. However, 3 families had decided to call an end to the 

use of outpatient care. The burden of therapy for the child was a decisive factor 

for 1 family. The parents ended (re)habilitation care after 6 years as a result of 

the combination of attending school, doing home work, and going to therapy. 

Professional assessment of the child’s educational and social achievements were 

reported by 1 family as a decisive factor. After 6 years of outpatient care, 

professionals were confident that the child would continue to achieve good 

functional and school results without outpatient care. The mother agreed to 

end care on the condition that professionals from the center would continue to 

participate in meetings with school staff and educational support therapists. 

Finally, the unusual disappearance of the child’s hearing loss after 2 years of care 

was an obvious reason for 1 family to end care-use. This incident is rare, 

314 Hardonk, et al.

according to the ENT specialist who treated the child; however, it is a 

documented medical phenomenon related to the development of the child’s 

brain in the early stage of life (Raveh, Buller, Badrana, & Attias, 2007). 

Instead of ending the use of (re)habilitation care completely, 2 families 

decided to end outpatient multidisciplinary care and replace it by private 

audiological support and listening and spoken language therapy closer to 

their home. They had confidence in their decision because it was explicitly 

supported by care professionals at their (re)habilitation center. 

The Trajectory to Educational Support at Home 

The mission of the service provider for educational support at home aims 

at supporting families in their daily environment as far as the parent-child 

interaction and the psychosocial well-being of all family members is concerned. 

This type of care is closest to the family and provides support from 

both a clinical and a social perspective. The parents recalled that educational 

support at home consisted of listening and spoken language and sensorymotor 

therapy, transfer of knowledge about hearing loss and the interaction 

with the child, and psychosocial and educational support for the parents. 

However, some parents felt that their interests, uncertainties, and emotions 

were neglected as a result of the strong focus on therapy and the lack of direct 

support for parents, which contradicts the mission statement of these services. 

Referral and Initiation of Educational Support at Home 

Important questions for this type of support are a) whether it is offered and 

initiated quickly after referral to the (re)habilitation center and b) how the 

timing and provision of support were experienced by parents. Familiarity with 

deafness was a factor that lead 3 families who have an older child with hearing 

loss to reject the offer of educational support at home. They were confident 

that their child would receive all necessary care at the (re)habilitation center. 

The families of the remaining 14 children were referred to educational support 

at home by professionals during, or immediately after, the pre-admission consultation 

at the (re)habilitation center with the care beginning shortly afterwards. 

This was different for 4 families, who reported time intervals of 3 to 36 months 

between admission and the start of educational support at home. One family 

was disappointed by the prospect of delay, but managed to circumnavigate this 

with the help of an acquaintance who knew the director of the (re)habilitation 

center. The mother emphasized that she and her husband faced a great deal of 

uncertainty and that they were not satisfied by the fact that special efforts 

had been necessary to receive support at home. Two other families were also 

disappointed about the delay of many months and the fact that they were never 

given a reason for it. One family reported a delay of 36 months after admission 

to the (re)habilitation center while they felt a need for psychosocial and 


pedagogical support during the first months after diagnosis. The rejection of the 

diagnosis by 1 father was also responsible for a 24-month delay of educational 

support at home. None of the parents reported any shifts in the use of services 

after the initiation of educational support at home. From these results it appears 

that delay in the initiation of educational support at home can lead to uncertainty 

and disappointment among parents, who value early initiation of this 

type of service and attention for parental support needs. 

End of Educational Support at Home 

Based on the accounts of the 14 families who received educational support 

at home, four types of experiences were reported by the parents. First, the 

parents of 8 children stated that the beginning of their child’s attendance at 

infant school (age 3) was an important marker for the decision to end 

the provision of educational support at home. Two families reported that they 

agreed to professional suggestion of a gradual reduction of educational support 

at home over a period of 6 months. However, most of these parents 

reported that care professionals ended the provision of educational support 

at home immediately after the child started school without offering the 

parents the opportunity to discuss the matter. Some parents received an 

explanation from the (re)habilitation center stating that this was their usual 

practice, but others reported that they were given no information, which 

made it harder for these parents to understand the decision to stop at-home 

care. Nevertheless, most parents reported that the need for this type of care 

had disappeared and that the general burden of care for the child had grown 

since the beginning of school attendance. 

Second, the beginning of preschool kindergarten in a MED cluster or a shift from an 

infant school to a school that belongs to a MED cluster lead to ending educational 

support at home for 2 families. The parents were reassured by care professionals 

who emphasized that the child would receive enough care in the MED cluster. 

Moreover, they felt that they had gained familiarity with their child’s hearing loss. 

Third, the perceived needs of the family played a role in 3 families’ experiences. 

For the family in which the child’s hearing loss had gradually 

disappeared, it is obvious that the need for educational support had disappeared. 

Two other families emphasised the connection of the family’s needs 

with the burden of care resulting in their initiative to end educational support 

at home. They reported that after some time—a few months in 1 family, 1 year 

in the other—they realized that this service was focused on therapy for the 

child. They felt that their child received enough therapy already and they 

needed some time and space with their child as an “ordinary family.” 

A fourth type of experience involved educational support at home continuing 

at the time of the interview, albeit with reduced frequency. The parents of 

1 child reported that in the first year, the auditory-verbal therapist aimed her 

efforts both at the child and the parents, but gradually the needs of the child 

316 Hardonk, et al.

decreased and support became focused on psychosocial and administrative 

issues. These parents felt unable to deal with these issues and considered the 

therapist a key person in the care of their child. 

The results indicate that many—but not all—families need for support at 

home gradually diminishes over time, which emphasizes the importance of 

early initiation. With regard to ending this type of support, no standardized 

approach appears from our analysis and interaction between parents and care 

professionals is important. 

Discussion 

This study demonstrates how differences in the care trajectories after UNHS 

relate to parental experiences of care-related decisions and interaction with care 

professionals. The analysis provides qualitative insight into the meaning of events 

and decisions related to the initiation and further use of (re)habilitation care. 

These findings emphasize the potential of a qualitative study design in this field. 

First, based on the UNHS program guidelines, it is perhaps not surprising 

that most of the families reported referral at the beginning of the care trajectory to 

one of the certified (re)habilitation centers. This, however, did not imply the 

existence of a standard trajectory of (re)habilitation care. Some parents’ experiences 

indicate that direct referral from UNHS to an ENT department created 

obstacles in the care trajectory. Parents experienced feelings of uncertainty 

and anxiety with regard to the future of the child because they received little 

more than a confirmed diagnosis. In addition, referral to an ENT department 

demanded more initiative from parents with regard to taking the next 

step towards consultation with a (re)habilitation center because many ENT 

specialists focused on diagnosis and audiological care and expected that the 

parents would contact a (re)habilitation center independantly. From a medical 

perspective, it may seem to be an easy step—from the ENT specialist’s 

office to the (re)habilitation center—however, the experiences of the parents 

in this study indicate that when support is limited to simple referral, this 

step can lead to psychological distress and even delay in care. 

Second, the parental perception of testing and diagnosis may lead to delay 

and interruption of the care trajectory. This analysis retains three important 

causes for delay and interruption: denial of the diagnosis and anxiety about 

the child’s future development, confirming conclusions drawn from previous 

studies (Meadow, 1968; Luterman, 1985; Kurtzer-White & Luterman, 2003); 

ethical issues surrounding medical acts necessary for diagnostic purposes, 

such as the rejection by one family of sedation necessary for BERA; and 

medical issues, such as unclear or false-negative test results. Care professionals 

may consider their influence in those matters as limited. For example, 

how can an ENT specialist know when negative BERA results are in fact 

false negatives? In such instances the experiences of the parents in this 

study indicate that ENT specialists and (re)habilitation professionals should 


ecognize the parental perception and provide active, continuous support. 

This could avoid situations where parents receive a negative test result or have 

the feeling that “something is not right,” and still do not take any further 

steps because a highly sophisticated test had failed to indicate a hearing loss. 

With regard to educational support at home, results indicate that from the 

parents’ perspective, support should transcend the focus on the child’s development 

and be sensitive to the social and psychological issues that parents 

face. Moreover, flexibility in the professional approach and regular consultation 

of the parents with regard to their needs is necessary. 

Limitations 

It is necessary to consider some methodological limitations with regard to 

the interpretation of results. First, notwithstanding the extensive efforts made 

to maintain the highest possible diversity, the perspective of immigrant families 

and families with one or more parents who are deaf are not reflected 

in our results. In general, empirical information about these specific groups 

is scarce; therefore, future study designs should deliberately aim to include 

these groups to investigate their particular experiences. Second, as far as data 

collection is concerned, there is the issue of participants recalling events and 

experiences that happened some time prior to the interview. Reported details 

of experiences could be forgotten or reconfigured in a story of the past. 

To deal with this issue, a qualitative life grid method (Hardonk et al., 2010a, 

b, c) was implemented and a second interview was conducted based on the 

first analysis. Third, while saturation was reached on all major criteria, it needs 

to be stated that this qualitative design was not aimed at representativeness in 

the quantitative sense. The idiosyncratic value of findings lies in uncovering a 

variety of relevant elements in the parental perspective on early care intervention, 

which is a necessary addition to the existing body of literature on UNHS 

and early intervention programs. Furthermore, a strength of this study lies in 

the fact that it used a UNHS program as the basis for sampling, as opposed to 

other studies on this subject (e.g., Brown et al., 2006; Fitzpatrick et al., 2007; 

McKellin, 1995; Storbeck & Pitman, 2008) in which sampling was done through 

early intervention services and organizations for the deaf. 

Finally, it should be noted that the data collection for this study was situated 

in Flanders, Belgium, implying that results could be different in other 

regions, especially those where early intervention services are not covered by 

public health insurance. This could negatively impact the accessibility of 

these services. 

Conclusion 

In general, we conclude that parental experiences with regard to screening, 

diagnosis, and (re)habilitation care form a complex reality surrounding the 

318 Hardonk, et al.

early care trajectory, resulting not only in delay but also in psychological 

distress (see also Burger et al., 2005), which could undermine the UNHS program’s 

goal of effective early intervention and care. These experiences are 

influenced by the support parents receive shortly after UNHS. Therefore, it 

is important for care professionals—as Baroch (2003) stated in his evaluation 

of hospital-based UNHS programs in the United States—to develop a support 

model in early intervention that will maximize support and continuous 

follow-up on referral during the first stages of the care trajectory. It might 

be suggested that families should be primarily referred to a (re)habilitation 

center as the starting point for further diagnosis and care after UNHS. However, 

the experiences of some families show that this cannot entirely rule out 

delay and lack of support, and the need for an adequate support model persists. 

This may be achieved through the implementation of case management, 

in which a care trajectory counselor provides support in psychosocial issues 

and decision making starting immediately after delivery of the UNHS results 

throughout the early care trajectory (Maes et al., 2001; Maes & Bruyninckx, 

2003; Maes & Goffart, 2002). Case management is more than administrative 

follow-up and aims at strengthening existing services through cooperation 

and support of families in between services. Research surrounding the later 

care trajectory and the use of other services could provide evidence to support 

the organization of counseling. 

Acknowledgements 

The authors report no conflicts of interest. The authors alone are responsible 

for the content and writing of the paper. The conceptualization, data collection, 

and part of the analysis in this study was funded by Howest University College 

in Flanders, Belgium. Recruitment of respondents was made possible thanks 

to the collaboration of Kind en Gezin (Child and Family), the children welfare 

organization for the Flemish Community in Belgium. We would like to express 

our gratitude towards both organizations and to our respondents for their 

willingness to support this study. 

References 

Anderson, I., Weichbold, V., D’Haese, P. S., Szuchnik, J., Quevedo, M. S., 

Martin, J., et al. (2004). Cochlear implantation in children under the age 

of two–what do the outcomes show us? International Journal of Pediatric 

Otorhinolaryngology, 68(4), 425–431. 

Arber, S. (2001). Designing samples. In N. Gilbert (Ed.), Researching social life 

(second edition) (pp. 58–84). London: Sage Publications Ltd. 

Baroch, K. A. (2003). Universal newborn hearing screening: Fine-tuning the process. 

Current Opinion in Otolaryngology & Head and Neck Surgery, 11(6), 424–427. 


Beadle, E. A., McKinley, D. J., Nikolopoulos, T. P., Brough, J., O’Donoghue, 

G. M., & Archbold, S. M. (2005). Long-term functional outcomes and 

academic-occupational status in implanted children after 10 to 14 years 

of cochlear implant use. Otology and Neurotology, 26(6), 1152–1160. 

Brown, M., Bakar, Z. A., Rickards, F. W., & Griffin, P. (2006). Family functioning, 

early intervention support, and spoken language and placement outcomes for 

children with profound hearing loss. Deafness and Education International, 8(4), 

207–226. 

Bunne, M. (1999). Qualitative research methods in otorhinolaryngology. International 

Journal of Pediatric Otorhinolaryngology, 51(1), 1–10. 

Burger, T., Spahn, C., Richter, B., Eissele, S., Löhle, E., & Bengel, J. (2005). 

Parental distress: The initial phase of hearing aid and cochlear implant 

fitting. American Annals of the Deaf, 150(1), 5–10. 

Declau, F., Boudewyns, A., Van den Ende, J., Peeters, A., & Van de Heyning, P. 

(2008). Etiologic and audiologic evaluations after universal neonatal hearing 

screening: Analysis of 170 referred neonates. Pediatrics, 121(6), 1119–1126. 

Eisenberg, L. S., Johnson, K. C., Martinez, A. S., Cokely, C. G., Tobey, E. A., 

Quittner, A. L., et al. (2006). Speech recognition at 1-year follow-up in the 

childhood development after cochlear implantation study: Methods and 

preliminary findings. Audiology and Neuro-Otology, 11(4), 259–268. 

Fielding, J. (2001). Coding and managing data. In N. Gilbert (Ed.), Researching 

social life (second edition) (pp. 227–251). London: Sage Publications Ltd. 

Fisher, P., & Goodley, D. (2007). The linear medical model of disability: 

Mothers of disabled babies resist with counter-narratives. Sociology of 

Health and Illness, 29(1), 66–81. 

Fitzpatrick, E., Coyle, D. E., Durieux-Smith, A., Graham, I. D., Angus, D. E., & 

Gaboury, I. (2007). Parents’ preferences for services for children with hearing 

loss: A conjoint analysis study. Ear and Hearing, 28(6), 842–849. 

Geers, A. E. (2004). Speech, language, and reading skills after early cochlear 

implantation. Archives of Otolaryngology-Head and Neck Surgery, 130(5), 634–638. 

Green, J., & Thorogood, N. (2004). Qualitative methods for health research. London: 

Sage Publications Ltd. 

Grill, E., Uus, K., Hessel, F., Davies, L., Taylor, R. S., Wasem, J., et al. (2006). 

Neonatal hearing screening: Modelling cost and effectiveness of hospitaland 

community-based screening. BMC Health Services Research, 6, 14. 

Hardonk, S., Bosteels, S., Desnerck, G., Loots, G., Van Hove, G., Van 

Kerschaver, E., et al. (2010a). Pediatric cochlear implantation: A qualitative 

study of the parental decision-making process in Flanders, Belgium. American 

Annals of the Deaf, 155(3), 339–362. 

Hardonk, S., Desnerck, G., Loots, G., Van Hove, G., Van Kerschaver, E., 

Sigurjónsdóttir, H. B., et al. (2010b). Congenitally deaf children’s care trajectories 

in the context of universal neonatal hearing screening: A qualitative 

study of the parental experiences. Journal of Deaf Studies and Deaf Education, 

16(3), 305–324. 

320 Hardonk, et al.

Hardonk, et al. (2010c). Investigating congenitally deaf children’s care trajectories: 

Development and implementation of a qualitative research methodology. 

Under review, Journal of Deaf Studies and Deaf Education. 

Incesulu, A., Vural, M., & Erkam, U. (2003). Children with cochlear implants: 

Parental perspective. Otology & Neurotology, 24, 605–611. 

Kerschner, J. E. (2004). Neonatal hearing screening: To do or not to do. Pediatric 

Clinics of North America, 51(3), 725–736. 

Kluwin, T., & Stewart, D. A. (2000). Cochlear implants for younger children: 

A preliminary description of the parental decision process and outcomes. 

American Annals of the Deaf, 145(1), 26–32. 

Kurtzer-White, E., & Luterman, D. (2003). Families and children with hearing 

loss: Grief and coping. Mental Retardation and Developmental Disabilities 

Research Reviews, 9, 232–235. 

Lang, H. G. (2003). Perspectives on the history of deaf education. In M. 

Marschark & P. Spencer (Eds.), Deaf studies, language and education (pp. 9–20). 

New York: Oxford University Press. 

Lewins, A. (2001). Computer assisted qualitative data analysis. In N. Gilbert 

(Ed.), Researching social life (second edition) (pp. 302–323). London: Sage 

Publications Ltd. 

Luterman, D. (1985). The denial mechanism. Ear and Hearing, 6(1), 57–58. 

Maes, B., & Bruyninckx, W. (2003). Organisatie en implementatie van trajectbegeleiding 

voor personen met een handicap in Vlaanderen. (Onderzoek in 

opdracht van het Vlaams Fonds voor Sociale Integratie van Personen met een 

handicap.) Leuven, Belgium: K.U.Leuven, Centrum voor Orthopedagogiek. 

Maes, B., & Goffart, K. (2002). Case management for people with disabilities. 

Australian Journal of Case Management, 4(1), 3–8. 

Maes, B., Van Hove, G., Van Puyenbroeck, J., Van Der Veken, K., Van 

Driessche, C., & Boone, M. (2001). Een kader voor de organisatie van 

vraaggestuurde ondersteuning voor mensen met een handicap en hun omgeving. 

(Onderzoek in opdracht van het Vlaams Fonds voor Sociale Integratie van Personen 

met een Handicap). Leuven/Gent, Belgium: Vakgroepen Orthopedagogiek. 

Marschark, M., Rhoten, C., & Fabich, M. (2007). Effects of cochlear implants 

on children’s reading and academic achievement. Journal of Deaf Studies and 

Deaf Education, 12(3), 269–282. 

McKellin, W. H. (1995). Hearing impaired families: The social ecology of 

hearing loss. Social Science and Medicine, 40(11), 1469–1180. 

Meadow, K. P. (1968). Parental response to the medical ambiguities of congenital 

deafness. Journal of Health and Social Behavior, 9(4), 299–309. 

Mehl, A. L., & Thomson, V. (2002). The Colorado newborn hearing screening 

project, 1992–1999: On the threshold of effective population-based universal 

newborn hearing screening. Pediatrics, 109(1), E7. 

Mezzano, P., Serra, G., & Calevo, M. G. (2009). Cost analysis of an Italian 

neonatal hearing screening programme. Journal of Maternal-Fetal and 

Neonatal Medicine, 12, 1–6. 


Miller, J. & Glassner, B. (2004). The “inside” and “outside”: Finding realities 

in interviews. In D. Silverman (Ed.), Qualitative research. Theory, method and 

practice (pp. 125–139). London: Sage Publications Ltd. 

Nelson, H. D., Bougatsos, C., & Nygren, P. (2008). Universal newborn hearing 

screening: Systematic review to update the 2001 U.S. Preventive Services 

Task Force Recommendation. Pediatrics, 122(1), e266–276. 

Neumann, K., Gross, M., Bottcher, P., Euler, H. A., Spormann-Lagodzinski, 

M., & Polzer, M. (2006). Effectiveness and efficiency of a universal newborn 

hearing screening in Germany. Folia Phoniatrica et Logopaedica, 58(6), 

440–455. 

Okubo, S., Takahashi, M., & Kai, I. (2008). How Japanese parents of deaf 

children arrive at decisions regarding pediatric cochlear implantation 

surgery: A qualitative study. Social Science and Medicine, 66, 2436–2447. 

Patton, M. Q. (2002). Qualitative research and evaluation methods (3th edition). 

London: Sage Publications Ltd. 

QSR. (2006). NVivo 7: Software for qualitative data analysis. Australia: QSR 

International Pty Ltd. 

Raveh, E., Buller, N., Badrana, O., & Attias, J. (2007). Auditory neuropathy: 

Clinical characteristics and therapeutic approach. American Journal of Otolaryngology, 

28(5), 302–308. 

Silverman, D. (1993). Interpreting qualitative data. Methods for analysing talk, 

text and interaction. London: Sage Publications Ltd. 

Storbeck, C., & Pittman, P. (2008). Early intervention in South Africa: Moving 

beyond hearing screening. International Journal of Audiology, 47(Suppl 1), S36–43. 

Strauss, A. L., Fagerhaugh, S., Suczek, B., & Wiener, C. (1997). Social organization 

of medical work. New Brunswick, N.J.: Transaction Publishers. 

Thompson, D. C., McPhillips, H., Davis, R. L., Lieu, T. L., Homer, C. J., & 

Helfand, M. (2001). Universal newborn hearing screening: Summary of 

evidence. Journal of the American Medical Association, 286(16), 2000–2010. 

Uilenburg, N., Kauffman-de Boer, M., van der Ploeg, K., Oudesluys-Murphy, 

A. M., & Verkerk, P. (2009). An implementation study of neonatal hearing 

screening in the Netherlands. International Journal of Audiology, 48(3), 108–116. 

Van Kerschaver, E., Boudewyns, A. N., Stappaerts, L., Wuyts, F. L., & Van de 

Heyning, P. H. (2007). Organisation of a universal newborn hearing screening 

programme in Flanders. B-ENT, 3(4), 185–190. 

Van Kerschaver, E., & Stappaerts, L. (2000). Algo Hearing Screening, report for 

1999. Brussels: Kind en Gezin. 

Van Kerschaver, E., & Stappaerts, L. (2001). Algo Hearing Screening, report for 

2000. Brussels: Kind en Gezin. 

Van Kerschaver, E., & Stappaerts, L. (2003). Algo gehoorscreening: rapport van 

de werkjaren 2001 & 2002. Brussels: Kind en Gezin. 

Verhaert, N., Willems, M., Van Kerschaver, E., & Desloovere, C. (2008). 

Impact of early hearing screening and treatment on language development 

and education level: Evaluation of 6 years of universal newborn hearing 

322 Hardonk, et al.

screening (ALGO) in Flanders, Belgium. International Journal of Pediatric 

Otorhinolaryngology, 72(5), 599–608. 

Young, A., & Andrews, E. (2001). Parents’ experience of universal neonatal 

hearing screening: A critical review of the literature and its implications for 

the implementation of new UNHS programs. Journal of Deaf Studies and Deaf 

Education, 6(3), 149–160. 

Young, A., & Tattersall, H. (2005). Parents’ of deaf children evaluative 

accounts of the process and practice of universal newborn hearing screening. 

Journal of Deaf Studies and Deaf Education, 10(2), 134–145. 

Young, A., & Tattersall, H. (2007). Universal newborn hearing screening and 

early identification of deafness: Parents’ responses to knowing early and 

their expectations of child communication development. Journal of Deaf 

Studies and Deaf Education, 12(2), 209–220. 


Appendix A: 

Example of a Lifegrid Survey 

324 Hardonk, et al.


Parent and Teacher 

Perceptions of Transitioning 

Students from a Listening and 

Spoken Language School to the 

General Education Setting 


The present study examines the perception of parents and teachers towards the 

transition process and preparedness of students who are deaf or hard of hearing from a 

listening and spoken language school in the Northeastern United States to a general 

education setting in their home school districts. The study uses a mixed methods design 

with in-depth interviews of a criterion-based sample of parents as the primary data 

gathering method. From the parent sample, teachers of the same child were surveyed 

regarding the transition and student preparedness for the general education setting. 

Interview transcripts and surveys were analyzed using a phenomenological data analysis 

technique and descriptive statistics. Findings of the analysis indicate that although 

the initiator and length of time for the process varied, parents and teachers were 

satisfied with the transition process. Parents identified several important components 

of transitioning. Findings further indicate students were adequately prepared and were 

maintaining academic progress, but needed more time for vocabulary development. 

Introduction 

The U.S. Department of Education reported “[I]n 1970, U.S. schools educated 

only one in five children with disabilities, and many states had laws 

excluding certain students, including children who were deaf, blind, emotionally 

disturbed, or mentally retarded” (2007, }5). Landmark court rulings 

in the 1970s resulted in changes to civil and educational rights for persons 

with disabilities. Most recently, the reauthorization of the Individuals with 

Natalie Rugg, Ph.D., is an Assistant Professor at La Roche College. Vicki Donne, Ed.D., is an 

Assistant Professor at Robert Morris University. Correspondence concerning this manuscript 

may be directed to Dr. Rugg at ncrr@hotmail.com. 

Transitioning Students 325

Disabilities Education Improvement Act (IDEA) in 2004 emphasized that students 

with disabilities are provided a free and appropriate education (FAPE) in 

the least restrictive environment (LRE). Oftentimes, a general education setting 

is considered the LRE and as a result, an increased number of students with 

disabilities are being educated in that setting (McHatton & Daniel, 2008). 

Students who are deaf or hard of hearing are no exception to increased enrollment 

in the general education setting. According to the Gallaudet Research 

Institute (GRI, 2009a), 59.9% of students who are deaf or hard of hearing across 

the United States receive their education in the general education classroom 

while 24.3% are educated in a special school for the deaf, day school, or residential 

school. Students reported the use of various modes of communication: 52% 

speech only, 34.9% sign with speech, 11.4% sign only, 0.2% cued speech, and 

1.5% another form of communication. Furthermore, of the children who use 

speechonlyastheirprimarymodeofcommunication,65%areeducatedinthe 

general education setting, 11.8% are educated in a self-contained class in a general 

education setting, 11.5% are educated in a resource room, 5.6% participated 

in listening and spoken language (LSL) schools and programs for the deaf, 2.4% 

are educated at home, and 3.7% listed “other” as their instructional setting (GRI, 

2009b). Currently, 52 schools world-wide belong to the organization OPTION 

Schools, Inc., that specialize exclusively in teaching children who are deaf or 

hard of hearing using a listening and spoken language approach (OPTION 

Schools, n.d.). At least 37 of these schools explicitly state within their mission 

or philosophy that transitioning students (also referred to as mainstreaming) to 

the general education setting is one of their goals (OPTION Schools, n.d.). 

Research on the experiences of students who are deaf or hard of hearing 

and in the general education setting document areas of success and difficulty. 

In a study by Lambropoulou (1997, as cited in Angelides & Aravi, 2006), 

children in an included classroom received very little support, especially in 

terms of differentiating instruction. Academics were more challenging and 

success required more time spent “catching up” by taking notes, meeting the 

teachers after hours, and studying. Foster (1989) noted similar results. One of 

her participants stated, “It wasn’t easy in school...the notes were written on 

the blackboard, and I was really frustrated because I wasn’t able to sit in the 

front” (p. 43). Consequently, the time needed to maintain academics was 

taken from other areas, including extracurricular activities. 

Despite the obstacles and frustrations experienced by individuals who are 

deaf or hard of hearing within the general education setting, positive outcomes 

were also experienced. Many researchers stated that although academics 

may be more challenging, academic achievement was higher for 

students with a hearing loss attending public schools compared to their peers 

attending special schools (Allen & Osborn, 1984; Lynas, 1999; Moores & 

Kluwin, 1989; Powers, 2001). A 5-year longitudinal study conducted by Antia, 

Jones, Reed, and Kreimeyer (2009) found that students with hearing losses 

ranging from mild to profound who participated in general education classes 

326 Rugg & Donne

for 2 or more hours per day had higher academic achievement scores when 

compared to other students who were deaf or hard of hearing in selfcontained 

settings. It was also found that “71%-79% of students scored in the 

average or above-average range in math, 48%-68% in reading, and 55%-76% 

in language/writing” (p. 306). Furthermore, “79%-81% of students made one 

or more year’s progress annually” (p. 293). In addition to better academic 

success, students’ spoken language was enhanced. The inclusion classroom is 

an environment with natural spoken language and communication. According 

to Harrison (1988, as cited in Angelides & Aravi, 2006), developing spoken 

language can help students gain more knowledge. Harrison also argued that 

“the environment of mainstream schools has higher goals, more requirements, 

and a richer curriculum than that in special schools” (p. 447). 

Several studies examined factors contributing to the success of students 

who were deaf or hard of hearing once placed in the general education 

setting. One such study, conducted by Luckner and Muir (2001), included 

20 students who were nominated by their current teachers to participate in 

the study, 13 teachers of the deaf, 19 general education teachers, 9 interpreters, 

2 notetakers, and 19 parents. Interview data revealed several recurring themes 

that influenced the students’ success: family involvement, self-determination, 

extracurricular activities, social skills/friendships, self-advocacy skills, communication 

with and support for general education teachers, pretaught/post-taught 

content and vocabulary being learned in the general education classroom, 

collaboration with early identification and early intervention service providers, 

reading, and high expectations. 

Powers and colleagues (1999) also reported that quality support was a critical 

factor for students who are deaf or hard of hearing to be successful within the 

general education classroom. Support could be classified as direct support, such 

as preteaching a lesson or providing pull-out instruction, or indirect, such as 

providing in-service support to teachers or educating peers about hearing loss. 

Similar findings were reported in a study of children who were deaf or hard of 

hearing who used listening and spoken language and who received their education 

in secondary general education schools (Hadjikakou, Petridou, & Stylianou, 

2008). Parent and teacher interviews indicated that the majority of parents 

believed that their child “could cope quite well or very well with the demands 

of the general school curriculum, and that their children could quite well or very 

well meet the requirements of the general school” (p. 24). Furthermore, every 

teacher replied that they believed the student who was deaf or hard of hearing 

benefited academically from being included in the general education classroom. 

A great majority of teachers also responded that the students could attentively 

follow the lessons, understand the lessons, and participate in the classroom. 

A review of the literature found no studies on the actual process of transitioning 

students who are deaf or hard of hearing from a specialized school into 

the general education setting. Research examining the process of transitioning 

from a specialized school into a general education placement or outcomes of 


those placements for students with any type of disability was also very limited. 

One study conducted by Knesting, Hokanson, and Waldron (2008) found that 

the transition for middle school students with mild disabilities took noticeably 

longer than expected. Some students required an “extended length of time...to 

learn about and become comfortable with school routines than their peers without 

disabilities” (p. 271). 

Statement of the Problem 

Very little research has been conducted to determine the preparedness of 

students who are deaf or hard of hearing entering the general education 

setting and their academic progress post-transition. As previously noted, 

studies involving students with other disabilities identified themes or factors 

important to the successful transition from a special school into the general 

education. Survey and interview research was available to identify factors 

reputed to promote the successful achievement of students who are deaf or 

hard of hearing once placed in the general education setting. Given the limited 

research pertaining to the transition process of students who are deaf or 

hard of hearing from a LSL school to the general education setting, there is a 

need to examine the transition process to determine the effectiveness of a LSL 

school program and a student’s preparedness to enter the general education 

setting. Thus, this research study sought to answer the following questions: 

What are parent perceptions toward the process of transitioning students 

from a LSL school into the general education setting? And how well are 

students from a LSL school prepared for the general education setting? 

Methodology 

Through the use of a mixed methods approach and using a phenomenological 

case study design, the collection and analysis of quantitative and 

qualitative data addressed the research questions posed in this study. 

Purposeful sampling, specifically criterion-based sampling, was employed. 

A review of student records at a LSL school located in the Northeast United 

States was conducted to determine eligibility of participants. In addition, 

the review of student records provided demographic information on the 

sample, e.g., date of enrollment, test scores, and grade point average (GPA). 

Interview and survey methods were used to collect data on perceptions of the 

transition process and preparedness for the general education setting. 

Instrumentation 

The authors developed two separate instruments: interview protocol questions 

for the parent participants (Appendix A) and a survey for the teacher 

participants (Appendix B). The Institutional Review Board at Robert Morris 

328 Rugg & Donne

University approved the study and permission was obtained from the LSL 

school. Then, a pilot study was conducted with 3 parents to determine the 

thoroughness and flow of the interview questions. As a result of piloting the 

interview protocol, additional questions were asked in an effort to gain further 

insight into the transition process. Those questions included topics pertaining 

to the transition meeting, such as who initiated it, was anyone opposed to it, 

and any memorable topics from the meeting; support services offered to the 

parents of students who are deaf or hard of hearing; and if the services provided 

by the LSL school extended to the home district. The interview consisted 

of 18 questions; 6 questions were Likert-scale items and 12 questions enabled 

open ended responses. The survey for the teachers consisted of 25 items including 

open-ended questions, a check-list, and selected-response items in the form 

of a Likert-scale followed by a section for comments. 

Setting and Transitioning 

To be considered for participation, students must have transitioned from 

the LSL school under study. Transitioning was an ongoing process that 

included the following elements (D. Williams, personal communication, 

February 15, 2011): 

Self-advocacy education of students who are deaf or hard of hearing 

while attending the LSL school that included course work in self-advocacy 

about hearing loss and self-advocacy as part of character building. 

Education of the parents through a yearly, optional transitional workshop 

offered by the school to explain the transition process, discuss 

considerations related to the general education environment, and facilitate 

a question and answer session. 

Transition meeting with team members at the LSL school, including 

parents, transition coordinator, teacher of the deaf or hard of hearing, 

and individuals providing additional support, i.e. speech-language 

pathologist and audiologist. Academics and a transition implementation 

timeline are discussed. 

Transition Individualized Education Program (IEP) meeting with the 

LSL school team and general school district to discuss appropriate placement 

based on academic strengths and needs. Optional services are 

offered by the LSL school and may include the following: 

o Student presentation: A small group of students who are deaf or hard 

of hearing present information about hearing loss, types of technology, 

and various listening devices (learned from the self-advocacy class) to 

other students or teachers at the district school. 

o Partial mainstreaming: Student may participate in the general education 

setting 1 day per week during the final quarter of the placement at 

the LSL school. 


o Professional development: LSL school may provide professional development 

to the district and school personnel on working with students 

with a hearing loss. 

o Consultation: LSL school may continue to support the district, if 

requested by either the parent or district, by providing consultative 

services. 

Procedures and Participants 

The population for this study was comprised of two distinct groups. Consistent 

with criterion-based sampling, the first group included parents 

of students who are deaf or hard of hearing who met the following three 

criteria: the student must have transitioned from the LSL school under study; 

the student must have transitioned after the 2004-2005 school year (the year 

in which the current mainstream coordinator was employed at the LSL 

school); and the student must currently be enrolled in a general education 

K-12 program. A total of 22 students met the criteria, thus 22 sets of parents 

made up the total parent population contacted. 

Parents of students who met the sampling criteria were asked via a letter 

to participate in an interview, and interested parents completed a consent 

form. Of the 22 parents contacted, 12 responded and were interviewed (55% 

response rate). Eight interviews (66%) were conducted via telephone and four 

interviews (33%) occurred in person. All parental participants were females. 

Demographic data pertaining to their children were obtained through a 

review of the LSL school records and are reported in Table 1. 

The age of entry into the LSL school averaged 3.5 years old while the 

median age was 3 years old. The mean length of attendance at the auditoryoral 

school was 7.8 years and the median transition age was 8.5 years old. The 

average grade in which students transitioned was 5th to 6th grade and the 

median was between 6th and 7th grade. All students transitioned after 2005, 

making the mean and median time in the general education setting 2.75 years. 

During the 2004-2005 school year, the LSL school offered services from a 

birth-to-3 center-based program through high school. However, the high 

school program was no longer offered in 2007-2008, requiring students 

of high school age to transition into a different setting. It is important to note 

that for the purposes of this study, the sample was representative of the 

population at the LSL school. 

At the interview, parent participants were asked for permission to contact 

the student’s current teacher. Upon receiving parental consent, another consent 

form was mailed to the special education supervisor at the student’s 

school. After consent from the supervisor was received, teachers were mailed 

the paper survey to fill out with completion of the survey indicating consent. 

The survey instrument was used as a means to gather data from teachers 

and achieve triangulation. 

330 Rugg & Donne

Table 1. 

Student demographic data 

Student Gender 

Hearing 

Loss 

Age of 

Diagnosis 

Type of Device & 

Age of Amp. 

Entry 

Age 

Years at 

LSL 

Transition 

Grade 

A F Profound 21 BIHA-2.0 2.8 11 7 

B F Profound 15 BIHA-1.4 CI1-2.7 2.7 10 8 

C M Mod-Sev 0 BIHA-0.5 5.8 3 4 

D M Mild- 6 BIHA-0.6 3.0 2 K 

E M Profound 3 BIHA-0.6 CI1–2.3 1.0 8 3 

F F Mod-Sev 36 BIHA-3.2 3.4 11 9 

G M Mod-Sev 31 UHA-2.8 4.4 9 6 

H M Profound 18 BIHA-1.7 CI1–2.1 4.0 2.4 K 

I M Profound 17 BIHA-1.4 CI1–2.2 3.1 6 3 

J M Profound 18 BIHA-1.7 CI1–12.0 3.0 11 9 

K F Profound 7 BIHA-1.1 CI1–3.11 3.6 11 9 

L M Profound 12 BIHA-1.3 CI1–6.3 5.2 9 8 

Note: CI = cochlear implant; BIHA = bilateral hearing aids; UHA = unilateral hearing aids 

The second sample group included current teachers of the deaf who taught 

students whose parents chose to participate in the study. If students no 

longer required hearing support services, language or reading teachers were 

asked to participate in the study. Based on the number of parent responses, a 

total of 12 teachers were asked to participate. All of the teachers provided 

itinerant services with the exception of 1 teacher who taught language arts. 

Of the 12 surveys sent to teachers, 7 were returned for a 58% response rate. 

Table 2 illustrates demographic information pertaining to the teacher participants. 

The average length of time teachers had worked with the student 

participants was 1.5 years. 

Table 2. 

Teacher demographic data 

Teacher Gender 

Teacher’s 

Position 

Corresponding 

Student 

Yrs. with Student in 

General Ed Setting 

Min/Week of 

Hearing Support 

Services 

1 F TOD/HH A 3.5 84 

2 F TOD/HH C 0.5 60 

3 F TOD/HH D 0.5 135 

4 F Language F 1.5 0 

Arts 

Teacher 

5 F TOD/HH J 1.5 30 

6 F TOD/HH K 0.5 630 

7 F TOD/HH L 3.5 Consult 

Note: TOD/HH = teacher of the deaf or hard of hearing 


Results 

The interview and survey yielded both qualitative and quantitative results. 

Interviews were transcribed then coded, and two themes emerged. Qualitative 

results included descriptions of the shared experiences of parents transitioning 

their children. Quantitative data were analyzed through the use of descriptive 

statistics to determine central tendency information, such as mean, median, 

and mode. 

Parent Perceptions of the Transition Process 

What are the parent perceptions toward the process of transitioning students 

from a LSL school into a general education setting? Throughout the interviews, 

it became evident that transitioning was a process that occurred over time and 

required planning and preparation. Phenomenological data revealed two main 

themes: Process of Transitioning Students (with 3 sub-themes) and Current Practices 

(with 2 sub-themes and 8 related aspects). 

Process of Transitioning Students 

In examining the process of transitioning, three related aspects emerged: 

Initiation and the Length of Time for the Process to Occur, The Transition Meeting, 

and Readiness Characteristics. The first sub-theme relates to the initiation of 

transitioning and the length of the process. The initiator, or the individual or 

entity responsible for initiating the topic of transitioning, varied. On two occasions 

the student was responsible for beginning the process. In four situations, 

the parent approached the school about transitioning the student. Three participants 

identified the reason for transitioning as being forced to do so because 

the LSL school no longer provided a high school program. The auditory-oral 

school was responsible for initiating the process for 1 student to go back into 

the home district, as parent participant D recalled, “[LSL school] came to us. 

By December, he had pretty much grown out of [LSL school] and what they 

could do for him.” 

Another parent participant noted that it was a “joint decision and a concurrent 

plan the whole time of the student’s enrollment.” In the final case, 

the home school district inquired as to why the student was not able to participate 

in the general education curriculum they provided. Parent participant L 

described, “They felt that they were looking at his IEP, his comments from his 

teachers...that he was ready to go.” 

Transitioning is a process that requires planning and preparation, which in 

turn translates into time. The length of time from the transition initiation to 

placement in the general education setting varied depending on the individual 

strengths or needs of the students. The least amount of time for the 

332 Rugg & Donne

process to occur was 1 year. The greatest amount of time for the process to 

occur took 3 years, but that was only for one student. In that case, the parent 

began the discussion of transitioning with the mainstream coordinator when 

the student turned school age and entered kindergarten. At the annual IEP 

meetings, the student’s progress and needs to successfully transition were 

addressed. It was determined at the beginning of second grade that this 

student would transition into a general education setting for third grade. 

The transition meeting was a critical component of the transition process and 

the second sub-theme to emerge. At that time, the team members, including the 

parents, the mainstream coordinator at the LSL school, the current teacher of 

the deaf, individuals providing additional support (such as speech-language 

pathologists or audiologists), and/or representatives from the general school 

district, gathered to discuss the most appropriate placement for the student 

and any additional supports he or she may have needed. With the exception of 

three students, all members of the transition team were in agreement that it 

was the appropriate time for each of the students to transition. One parent 

indicated that the principal of the receiving school, which happened to be 

parochial, was opposed to accepting her child. Two of the other parent 

participants said that they themselves were opposed to the transition (these 

students were required to transition due to the LSL high school closure). 

The third sub-theme was the readiness characteristics of the student. Five 

parent participants indicated that they believed their child was ready to 

transition based on academic reasons. Parent participant I commented, “I 

would just say because of how well he was doing; his grades.” Two parents 

indicated that their child was not being academically challenged. Parent 

participant H recalled, “I think he was one of the higher functioning children 

in his class and he wasn’t being challenged.” Some of the parent 

participants indicated that the student was not ready to transition; however, 

the LSL school no longer offered services beyond the eighth grade 

level. Parent participant K summarized her concerns as “I don’t know if 

you’re ever ready to transition. I didn’t want her to transition because of the 

small class size.” 

Current Practices 

Two sub-themes developed as a result of analyzing the data on current 

practices: Effective Practices and Suggested Improvements. Participants shared 

experiences they felt were beneficial to the students’ transition as well as 

suggestions for improvement. During the interview, participants were asked, 

“Were you, as a parent, given any pointers or tips for the transitioning 

process?” Two of the parent participants named an evening training session 

while 2 other parents listed the mainstream coordinator’s willingness to attend 

local school district meetings. Eight of the parent participants did not recall 

any specific advice being given; however, further analysis exposed positive 


esults from every participant. Therefore, four aspects emerged under effective 

practices: Supportive Staff Members, The Student Presentation Program, 

Partial Mainstreaming, andParent Transition Workshop. 

Two parent participants explicitly stated how grateful they were to have 

the mainstream coordinator attend IEP meetings concerning the student 

at the receiving district. Parent participant D stated, “They could not have 

been more helpful and more supportive—their willingness to attend meetings 

and go anywhere and fill out paperwork. They could not have been 

any better.” Parent participant B had the same opinion and stated, “I always 

ask for someone from [LSL school] to accompany me to any meeting we 

have with the school district and still do since I don’t feel that much trust 

or confidence in [the home district’s] dealings with my daughter.” Follow-up 

comments indicated a general lack of communication, coordination, and 

follow-up of district services. 

As part of the transition process, students at the LSL school learned about 

audiograms, hearing loss, amplification devices, and cochlear implants. At 

the transition meeting, the mainstream coordinator offered the opportunity 

for the students to present this information to a group of peers at the receiving 

district. The purpose of this experience was two-fold. First, it provided 

students from the LSL school an opportunity to practice verbal presentation 

skills. Secondly, it was educational for students and faculty in the receiving 

district to have a basic understanding of hearing loss and its implications for 

communication and education. Two parents were extremely enthusiastic 

about this program. Parent participant C described her thoughts: 

“I think it’s important that [LSL school] went to visit the school district and 

let other kids know [about the student’s] hearing impairment [sic] and that 

they feel comfortable with [student]. I think that’s really been wonderful 

and the teachers at [LSL school] telling the teachers at [home district] what 

to expect or what to do, or making the classrooms less noisy and more 

acoustic, and to make sure he’s listening and not just that he’s hearing, that 

he’s listening and paying attention. Little things, sometimes it’s these little 

things that are just so great.” 

Parent participant A concurred: “They went to the school and explained and 

talked about their [cochlear] implants. I think that helped.” 

Another transition program component offered by the LSL school was 

partial mainstreaming. If the receiving district agreed, the student had the 

opportunity to participate in the general education setting 1 day per week for 

the last academic quarter prior to full transitioning. The purpose of this experience 

was for students to become comfortable with the environment, including 

locations of classrooms and other important areas; to increase their awareness 

of higher background noise and larger group settings; to become comfortable 

with new equipment, if applicable; and to meet new peers. The goal was 

334 Rugg & Donne

to put students at ease so that they would be familiar with their new surrounding 

and could better focus on academics the following year. Of the 12 participant 

families, five students participated in the partial mainstreaming 

program. Three parent participants identified the partial mainstreaming 

experience as extremely beneficial. Parent participant K remarked, “She went 

on Fridays and just worked on changing classes, just to get used to the bigger 

school...definitely a benefit. 100% benefit.” Parent participant J recalled 

the experience: 

“Actually at [home district] ...they took him there once a week; he went 

there in May before he went there in the fall...they selected a freshman, 

a student that was a well-rounded and mature person, to take him around 

to all his classes every Friday. That was a really, really good thing for 

[student] and that was a great thing [school district] did. I don’t know that 

all school districts do that, but it was really a good thing. He felt comfortable 

going there in the fall because he was familiar with the campus, 

some of the classrooms, the lunch room, that kind of thing.” 

At the end of the 2007-2008 school year, the LSL school began offering one 

evening session for the parents of students who were transitioning to explain 

the process and what to expect, and to answer any additional questions. Out 

of 6 parent participants who had the opportunity to attend these sessions, 

2 parents took advantage of this program and both commented on its helpfulness. 

According to parent participant C, “[LSL school] had an evening session 

for the parents about the transition process with guest speakers and this was 

extremely helpful. There was always support and encouragement on a continuous 

basis and this was assuring.” Parent participant I was of the same opinion, 

“The one training session that [mainstream coordinator and principal] 

were involved in was helpful.” 

In addition to the sub-theme of effective practices, the sub-theme of 

suggested improvements emerged as a result of the final formal question 

of the interview, which asked the participant for any suggestions for improvements 

based on her child’s experience. Throughout the interview, participants 

were generally positive when speaking about their experience with the 

transition process, the student’s education, and support. Five parent participants 

clearly indicated their satisfaction with the process; all of these participants’ 

children were transitioned in sixth to ninth grade and all had teachers 

who participated in completing the survey. Parent participant A stated, 

“I know a lot of people transitioned a lot earlier, but I was really happy with 

[LSL school] and I think [student] transitioned at a good time.” Although 

few parents had suggestions, four related aspects were discovered through 

this question: Continued Parent Transition Workshop, Become Active in the 

Community, Involving the Receiving District, andMore Frequent Discussions of 

the Topic. 


Two parent participants commented on the value of the evening session 

focusing on the transition process. One of those participants suggested an 

enhanced support group may be beneficial. Parent participant I posited: 

“You know what probably wouldn’t be a bad idea is maybe to have parents 

get together who are transitioning with parents who have been through it. 

[M]ake arrangements to do that so you can sort of listen to each other and 

ask what experiences are, and maybe the things you don’t know you’re 

going to learn from them.” 

Three parent participants commented on various aspects of the receiving 

district including knowledge of the transition process and supports they 

initially provided. Parent participant C stated, “I just think it’s really imperative 

for the home school district to be a part of that team; just the transition 

process.” Parent participant B expressed frustration with the process of 

scheduling a hearing support teacher and the lack of communication that 

occurred within the receiving school district. 

One parent participant (H) felt strongly that the topic of transitioning 

should be discussed more frequently. She was of the opinion that since 

transitioning students back to the general education setting was the auditoryoral 

school’s goal, a detailed plan should be in place and discussed on a regular 

basis; “I just wish there was a better road map for that.” 

These themes, sub-themes, and aspects explored the thoughts and opinions 

that parents provided indicating what they believe is currently working and 

including suggestions for improving the transition process. Together, this 

qualitative data described the parent perspectives of the transition process 

from a LSL school into the general education setting. Finally, quantitative 

data confirmed these narratives. Parents were asked how satisfied they were 

with the auditory/oral school’s role in the transition process. Likert scale 

responses indicated that 66.7% of parents reported very satisfied, 22.2% 

reported satisfied, and 11.1% reported somewhat satisfied. 

Student Preparedness for General Education 

How well are students from a LSL school prepared for the general education 

setting? To address this research question, student records at the LSL 

school were reviewed to obtain student achievement data. Parents were 

interviewed regarding their perceptions of their child’s preparedness. In 

addition, teacher survey data on perception of preparedness, student placement, 

performance, and support needed while in the general education environment 

were collected. 

Parent participants were asked to rate, using a Likert-scale format, 

the extent to which they believed their child was prepared to transition into 

336 Rugg & Donne

the general education setting. Interview data indicated that all parents 

believed their child was very prepared or prepared, and no parent answered 

somewhat prepared or not prepared. 

Teacher participants were surveyed to determine if they believed that the 

student was adequately prepared to enter the general education classroom. 

Six out of 7 (86%) teacher participants answered yes, they believed the 

student was adequately prepared. One teacher participant did not answer 

with a yes/no response, but stated “I’m not sure how the initial transition 

was; now [student] is doing well” (referring to student D). 

Teacher participants also reported on the specific academic subjects where 

the student was included in the general education setting. Six of the 7 students 

were included for reading and language. Teachers reported that two students 

received supplemental pull-out instruction in reading. Supplemental pull-out 

instruction was provided for four students and push-in instruction was provided 

for one student in language. All students were included for math, 

science, social studies, physical education, and electives (electives varied 

based on the grade level of the student and included computer, health, library, 

art, music, study skills, and technical education). 

To obtain additional information on the level of support students needed 

in the general education setting, teachers were asked to compare the needs 

of a student who was deaf or hard of hearing to his/her classmates with 

typical hearing. Specifically, does the student need extra time or help 

in completing assignments; need extra time or help with vocabulary; or experience 

difficulty staying on task. Using a Likert-scale to respond to each 

question, teacher participants were given the option of 1-5 where one equals 

much less, twoequalsless, threeequalsno additional, four equals more, and five 

equals much more. Responses for individual students are illustrated in Table 3. 

Only 14% of teachers believed that students needed much more time 

to complete assignments, 57% reported no additional time was necessary, 

and 29% indicated that students required less or much less time when completing 

assignments. When asked about extra time/help for developing 

vocabulary, 58% of the teacher participants believed that students required 

more or much more help when developing vocabulary, 14% thought that 

students required no additional time or help, and 28% felt that students 

needed less or much less time or help. With regard to student ability to stay 

on task, 14% believed that students had much more difficulty staying on 

task and the majority of respondents, 86%, thought that the students had 

no difficulty, less difficulty, or much less difficulty staying on task. 

A third means of addressing the research questions was to analyze 

how well students maintained academic progress once they were in the 

general education setting. Analysis utilized state assessment, GPA, and 

parent participant interview data. State assessment data in the subjects of 

reading, writing, and math were gathered from the last year of attendance 

at the LSL school through a review of school records and the current 


Table 3. 

Supplemental academic information 

Student 

Extra Time/Help in 

Completing Assignments 

Extra Time/Help Developing 

Vocabulary 

Difficulty Staying 

on Task 

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 

A X X X 

B 

C X X X 

D X X X 

E 

F X X X 

G 

H 

I 

J X X X 

K X X X 

L X X X 

performance in the general education setting was obtained from teacher 

survey responses. As the state assessment is not required to be administered 

in every grade, availability of participant data in this area was variable. 

For 3 students with available LSL and public school state assessment results, 

proficiency levels remained constant; only 1 student scored in the proficient 

range and this was across all academic areas. In addition, for 1 student, 

data were available from the general education school only and this student 

scored proficient in both reading and math (participant transitioned in 

kindergarten thus no state assessment was administered while attending the 

LSL school). 

Final GPA from the last year of attendance at the LSL school was compared 

to the same data regarding the student’s current performance in the general 

education setting. Analysis revealed that 5 of the 7 students maintained their 

GPA (two maintained a 3.0-3.49 GPA and three maintained a 3.5-4.0 GPA). 

Further, while in the general education, the GPA of student D improved from 

between 3.0-3.5 to between 3.5-4.0 while the GPA of student L slightly 

declined from between 3.5-4.0 to between 3.0-3.49. Please note that no data 

were collected on any adaptations regarding grading. 

Finally, parent participants rated their child’s academic performance on a 

Likert-scale (extremely poor to extremely well). From the parents’ perspectives, 

responses indicated that students were doing well or extremely well academically 

(six out of seven students) with only 1 parent responding average. These 

results were consistent with the teacher responses. Thus, where data were 

available, results of the above analysis indicate that students maintained academic 

progress. 

338 Rugg & Donne

Discussion 

Quantitative data gathered indicate that the majority of parents were satisfied 

with the transition process, while only 1 parent answered somewhat 

satisfied. Qualitative data revealed some interesting aspects regarding the 

transition process. The initiator varied based on the needs of the student. 

Parent participants F, J, and K stated that their children were required to 

transition because the LSL school no longer offered a high-school program; 

otherwise, they would have allowed their child to complete his or her education 

and receive a diploma from the LSL school. Table 3 shows that all of these 

students needed no additional or much less time or help completing assignments 

and staying on task in the general education setting. Responses for 

developing vocabulary ranged from no additional time or help to much more 

additional time or help, revealing that two of the students may require additional 

support services. Also, teacher and parent responses indicated that these 

students were maintaining academic progress. Overall, the length of time for 

the transition process to occur ranged from as little as 1 year to as long as 

3 years. This may indicate that a set procedure was not in place, which could 

affect the consistency and/or thoroughness of the transition process. 

The factors contributing to the success of parents’ overall satisfaction with 

the transition process can be found in effective practices, under current practices. 

Parent participants B and D, whose children transitioned more than 

4 years ago, recalled the supportive staff members, which demonstrated a 

strong impression made by the LSL school. The related aspect of partial 

mainstreaming was highly regarded by parents who had the opportunity to 

participate in this program. The research of Knesting et al. (2008) that focused 

on middle school students with mild disabilities found that learning the 

routines of daily activities, such as navigating the school and opening lockers, 

caused a range of anxiety among students. This supports the goal of partial 

mainstreaming, which is to alleviate the anxiety so students can focus on 

academic content the following year. Another effective practice included the 

parent transition workshop, to provide information regarding expectations of 

the upcoming transition and answer questions. Kemp (2003) reported similar 

findings that suggested support on various levels (choosing schools, visiting 

the future school, and meeting with the staff) was an important component to 

the parent comfort level of transitioning. 

The final topic pertaining to parent perspectives toward the transition process, 

suggested improvements, revealed four related aspects. Continuation of 

a parent transition workshop was suggested because this program was a 

recent addition to the transition process and parents wanted to ensure that it 

remained so due to the perceived benefit. Parents also suggested becoming 

active in the community. Because students do not attend a neighborhood 

school, they may not have the opportunity to socialize or make friends with 

neighborhood children. Knesting et al. (2008) noted the importance of peer 


elations: “[T]he sooner peer connections can be made for students with mild 

disabilities, the more likely their sense of belonging and adjustment to middle 

school will fall into place” (p. 274). Three parent participants suggested 

involving the receiving district in the transition process. The students participated 

in many of the transition activities, including the required course 

work, the student presentation program, and the partial mainstreaming experiences. 

The LSL school implemented professional development and consultation 

services to the receiving district for two of those participants. The 

student’s teacher of the deaf, speech-language pathologist, audiologist, and 

the mainstream coordinator from the LSL school traveled to the receiving 

district to meet with the faculty and staff and provided in-services regarding 

hearing loss in general as well as modifications specific to that child. Additionally, 

the receiving school was able to contact any of the team members 

to discuss student specific questions or concerns. Of those 3 parents who 

suggested involving the receiving district, only 1 teacher participant returned 

the survey, demonstrating warranted concerns at the district level. Finally, 

more frequent discussions of the topic were suggested, which indicated that 

parents may have felt uncomfortable with the planning, preparation, and/ 

or execution of the transition. If parents had been more informed and an 

outlined plan was in place, this topic may not have arisen. However, the 

uncertainty of the future and change of settings from a comfortable environment 

to an unknown environment may always cause anxiety, regardless of 

how detailed a transition plan may be. Results from the parent interviews 

provided this particular LSL school with areas of strength and programs to 

continue as well as areas in which to modify or improve. Results further 

emphasized that transitioning is a team process. 

When examining the results of the students’ preparedness, findings of 

the teacher survey revealed that every student except one was included in 

the general education setting for all subject areas. Not surprisingly, the subject 

area in which the single student received specially designed instruction 

was reading. Geers, Tobey, Moog, and Brenner (2008) found that “early 

cochlear implantation had a long-term positive impact on auditory and 

verbal development, but did not result in age-appropriate reading levels 

in high school for the majority of students” (p. 21). The present study found 

that although 86% of the students using cochlear implants were instructed 

in the general education setting for reading and language and 100% of the 

students for all other subject areas, 29% of the students received additional 

reading support outside of the classroom, 57% of the students received additional 

language support outside of the classroom, and 14% of the students 

received classroom push-in language support. These results were higher 

than the national average for students who are deaf or hard of hearing 

using listening and spoken language communication, which is reported to 

be 65% of students in the general education setting and 11.5% in a resource 

room (GRI, 2009b). One possible explanation is the higher percentage of 

340 Rugg & Donne

students at the LSL school with cochlear implants (66%) than nationally 

reported (9.7%; GRI, 2009b). 

Table 3 illustrated the responses pertaining to students’ need for extra time 

or help completing assignments and developing vocabulary as well as their 

ability to stay on task. Findings demonstrated that developing vocabulary was 

an area of concern for four students. Overall, results indicated that developing 

vocabulary was a true weakness and not a matter of the students’ behavior or 

inability to complete assignments. This is consistent with a large body of 

research documenting the vocabulary delays of students who are deaf or hard 

of hearing (Lederberg & Spencer, 2001; Marschark, 2009). 

To determine how well students were maintaining academic progress, data 

were obtained from three sources: the LSL school GPA and state assessments 

scores, the general education GPA and state assessment scores, and the parent 

interviews. According to data analysis, all of the students were maintaining a 

3.0 GPA or better. Of the 4 teachers who reported state assessment scores, half 

of the students attained a proficient level on reading, language, and math 

whereas the other half scored below basic, with the exception of a basic score 

in one math category. Although the small data set makes substantive statements 

regarding maintenance of academic progress problematic, these data 

were one small piece adding support to the transition process and student 

preparedness for the general education environment. 

Limitations 

This study contained certain limiting elements, some of which are commonly 

critiqued in a mixed-methods design. The present study utilized criterion 

sampling, which may limit generalizability of the results. Although 

generalizability was not the intended goal of this study, the researcher acknowledged 

the concept of transferability (Lincoln & Guba, 1985). It was 

anticipated that information from the present study could be useful in similar 

contexts and this concern was addressed by providing rich descriptions of 

the participants and the context in which this study was conducted. Participation 

was on a volunteer basis and all parent and teacher participants were 

female. Consequently, the population of all students who are deaf or hard of 

hearing and transitioning may not be accurately represented. 

In qualitative data analysis, the researchers bear the responsibility 

of accurately interpreting the data; therefore, it is subjective in nature. One 

researcher knew some of the participants, which may have influenced 

or affected the interviewees’ responses. They may have attempted to offer 

responses they perceived the researcher was seeking or they thought might 

be helpful, or they may have been guarded and less candid in their responses 

(Bloomberg & Volpe, 2008). These limitations were addressed in a variety 

of ways. First, participant names and any identifying information were 

removed from transcripts to prevent bias during the coding process. To 


address participant reactivity, the researcher assured the participants’ anonymity 

by signing a confidentiality agreement. In addition, triangulation of 

data was achieved. 

Conclusion 

Recent legislative mandates and the movement towards inclusion have 

resulted in increased numbers of students with disabilities being served in 

the general education setting. Consistent with these laws, the primary goal of 

a LSL school is for students with a hearing loss to transition into the general 

education setting at grade level, needing minimal additional support (AG 

Bell, 2010). The success of the transition process and the actual transition 

varied among students. According to parent and teacher participants, successful 

indicators of the transition process include the amount of time spent 

in the general education setting, academic scores, and the students being 

challenged appropriately. 

Limited research exists pertaining to how parents and teachers perceive the 

transition process from a LSL school or any other specialized school into the 

general education setting. This was surprising given the recent impetus for 

inclusion of students with disabilities. Although the findings of the present 

study were specific to the population of parents and teachers who worked 

with students from a particular LSL school, they addressed specific concerns 

that related to previous research. These findings could be used to evaluate and 

adjust programs that prepare students for the transition and the process for 

transitioning students. With a specific protocol to determine a student’s readiness 

and a roadmap to guide the process from beginning to end, parents may 

feel more comfortable with the process. Optimally, an exit criteria checklist 

indicating students’ individual academic and social readiness should not only 

be developed, but also embedded as mandatory institutional practices. 

Many opportunities exist for additional research in the area of transitioning 

students who are deaf or hard of hearing into the general education setting. 

Based on the findings of this study, additional research might include student 

perspectives of the transition process and general education setting experiences, 

or the inclusion of the perspectives of the teacher of the deaf at the LSL 

school. Also, replication of this study to include other LSL schools’ or other 

specialized schools’ transition practices would be beneficial. Finally, future 

research might identify a protocol of student readiness skills in relation to the 

transition process. 

References 

AG Bell (Alexander Graham Bell Association for the Deaf and Hard of Hearing). 

(2011). Listening and spoken language approaches. Retrieved November 3, 

2011, from http://nc.agbell.org/netcommunity/page.aspx?pid=758. 

342 Rugg & Donne

Allen, T. E., & Osborn T. L. (1984). Academic integration of hearing impaired 

students: Demographics, handicapping, and achievement factors. American 

Annals of the Deaf, 129(2), 100–113. 

Angelides, P., & Aravi, C. (2006). A comparative perspective on the experiences 

of deaf and hard of hearing individuals as students at mainstream 

and special schools. American Annals of the Deaf, 151(5), 476–487. 

Antia, S., Jones, P., Reed, S., & Kreimeyer, K. (2009). Academic status and 

progress of deaf and hard-of-hearing students in general education classrooms. 

Journal of Deaf Studies and Deaf Education, 14(3), 293–311. 

Bloomberg, L. & Volpe, M. (2008). Completing your qualitative dissertation: A 

roadmap from beginning to end. Thousand Oaks, CA: Sage Publications. 

Foster, S. (1989). Reflections of a group of deaf adults on their experiences in 

mainstream and residential school programs in the United States. Disability, 

Handicap & Society, 4(1), 37–56. 

Gallaudet Research Institute (GRI). (2009a). Regional and national summary 

report of data from the 2007-08 annual survey of deaf and hard of hearing 

children and youth. Washington, DC: GRI, Gallaudet University. 

Gallaudet Research Institute (GRI). (2009b). Special tabulations of data from 

the 2007-2008 annual survey of deaf and hard of hearing children and 

youth. Washington, DC: GRI, Gallaudet University. 

Geers, A., Tobey, E., Moog, G., & Brenner, C. (2008). Long-term outcomes of 

cochlear implantation in the preschool years: From elementary grades to 

high school. International Journal of Audiology, 47(2), S21–30. 

Hadjikakou, K., Petridou, L., & Stylianou, C. (2008). The academic and social 

inclusion of oral deaf and hard-of-hearing children in Cyprus secondary 

general education: Investigating the perspectives of the stakeholders. 

European Journal of Special Needs Education, 23(1), 17–29. 

Harrison, D. (1988). The education of hearing impaired children in local ordinary 

schools: A survey. The Education of the Deaf: Current Perspectives. London: 

Croom Helm. 

Kemp, C. (2003). Investigating the transition of young children with intellectual 

disabilities to mainstream classes: An Australian perspective. International 

Journal of Disability, Development and Education. 50(4), 403–433. 

Knesting, K., Hokanson, C., & Waldron, N. (2008). Settling in: Facilitating 

the transition to an inclusive middle school for students with mild disabilities. 

International Journal of Disability, Development and Education. 55(3), 265–276. 

Lederberg, A., & Spencer, P. (2001). Vocabulary development of deaf and 

hard of hearing children. In Clark, M., Marschark, J., & Karchmer, M. 

(Eds.), Context, cognition, and deafness (pp. 88–112). Washington, DC: Gallaudet 

University Press. 

Lincoln, Y. & Guba, E. (1985). Naturalistic inquiry. Thousand Oaks, CA: 

Sage Publications. 

Luckner, J., & Muir, S. (2001). Successful students who are deaf in general 

education settings. American Annals of the Deaf, 146(5), 435–444. 


Lynas, W. (1999). Supporting the deaf child in a mainstream school: Is there a 

best way? Support for Learning, 14(3), 113–122. 

Marschark, M. (2009). Raising and educating a deaf child: A comprehensive guide 

to the choices, controversies, and decisions faced by parents and educators (2 nd ed.). 

New York: Oxford University Press. 

McHatton, P. & Daniel, P. (2008). Co-teaching at the pre-service level: Special 

education majors collaborate with English education majors. Teacher Education 

and Special Education, 31(2), 118–131. 

Moores, D. F., & Kluwin, T. N. (1989). Mathematics achievement of hearing 

impaired adolescents in different placements. Exceptional Children, 55(4), 227-235. 

OPTION Schools. (n.d.) Communication options for your child who is deaf or hard of 

hearing. Retrieved October 24, 2011, from http://auditoryoralschools.org/ 

communicationoptions.aspx. 

Powers, S. (2001). Investigating good practice in supporting deaf pupils in 

mainstream schools. Educational Review, 53(2), 181–189. 

Powers, S., Gregory, S., Lynas, S., McCracken, W., Watson, L., Boulton, A., 

et al. (1999). A review of good practice in deaf education. London: Royal 

National Institute for Deaf People. 

U.S. Department of Education. (2007). Special education and rehabilitative 

services: Archived – a 25 year history of the IDEA. Retrieved October 24, 2011, 

from http://www2.ed.gov/policy/speced/leg/idea/history.html. 

344 Rugg & Donne

Appendix A: 

Parent Interview Protocol Questions 


346 Rugg & Donne

Appendix B: 

Survey for Teachers 


348 Rugg & Donne


350 Rugg & Donne



Commentary 

Literature Reviews 


Introduction 

The primary purpose of a literature review is to assist readers in understanding 

the whole body of available research, informing readers on the strengths 

and weaknesses of studies within that body (De Los Reyes & Kazdin, 2008). It 

is defined by its guiding concept or topical focus: an account of what was 

previously published on a specific topic. This prevents reliance on one research 

study that may not be in accordance with findings from other studies (Dunst, 

Trivette, & Cutspec, 2002). 

All practitioners who work with children with hearing loss have a professional 

obligation to be current in their knowledge base and, as such, to 

maintain a basic library of information. However, given the multitudinous 

cross-cultural journals, books, conferences, and electronic sources of information, 

keeping up with recent developments and research findings can be an 

impossible, if not daunting, process. Therefore, the value of good literature 

reviews can never be underestimated. 

Comprehensively reviewing and publishing aggregate research findings 

that pertain to a topic are important because such findings can: 

Represent an important scientific contribution. 

Guide the decision-making process of practitioners, administrators, and 

parents. 

Facilitate the development of practice guidelines. 

Strengthen advocacy capacity. 

Enhance professional development. 

Provide opportunities for practitioners who might like to publish yet do 

not have necessary resources. 

Establish the author as an “expert” on the research question. 

Ellen A. Rhoades, Ed.S., LSLS Cert. AVT, is an auditory-verbal trainer and consultant. 

Correspondence concerning this article can be directed to Dr. Rhoades at ellenrhoades@comcast.net. 

Literature Reviews 353

Guide practitioners into new lines of inquiry, improving methodological 

insights. 

Facilitate the direction of research by determining what needs to be done. 

Review and expand the topical lexicon. 

Place the body of research in a historical context. 

Enable researchers to secure substantial grant funding for research. 

Uncover many reasons why a larger body of evidence provides unequivocal 

or equivocal support for a particular strategy in multiple circumstances 

or with different environmental variables. 

(Baum & McMurray-Schwarz, 2007; Dunst et al., 2002; Grady & Hearst, 2007; 

Hemingway & Brereton, 2009; Randolph, 2009.) 

Types of Literature Reviews 

Literature reviews can be published as a book, a book chapter, a dissertation, 

a stand-alone manuscript, or as a prelude that provides justification for a 

clinical study submitted for publication in peer-review journals, e.g. The Volta 

Review. Regardless of how a review is presented for publication, there are 

different levels or types of literature reviews, some more acceptable than 

others for special purposes. In general, three basic types of literature review 

reflect a continuum of detail: narrative, systematic, and meta-analytic reviews. 

Narrative Review of the Literature 

Narrative reviews, sometimes referred to as overviews or standard/traditional 

reviews of the literature, critically appraise and summarize the literature relevant 

to an identified topic (Hemingway & Brereton, 2009). This type of literature 

review is often integral to a position paper or presented as background 

reading immediately preceding the research study in a manuscript submitted 

for publication. These papers tend to begin with an explanation of the rationale 

for the selected topic, providing a historical framework for the research 

study and the reason for examining studies relevant to the topic (Baum & 

McMurray-Schwarz, 2007). Narrative reviews often draw together major 

arguments in a field of discourse or provide a significant historical review of 

an important aspect of intervention practices for families and their children 

with hearing loss. 

A good narrative review is an objective-focused literary review of relevant 

studies with selection of those studies based on some criteria, such as studies 

published within a certain time period (Shank & Villella, 2004). As stated by 

Humphrey (2011), a qualitative review paper is made great by the fact that its 

author(s) organized the literature, framed it well, and then provided readers 

with a roadmap for the future. Although the aggregate studies are not necessarily 

international in scope and may not include a search for unpublished 

354 Rhoades

data on a topic, the reviewer states the criteria for selection of studies 

reviewed. The validity of the studies are discussed as part of the reviewer’s 

broad, qualitative, well-stated (but critical), and accurate evaluation of selected 

studies (Archbold, Gregory, Lutman, Nikolopoulos, & Sach, 2005; Collins & 

Fauser, 2005; Shank & Villella, 2004). Based upon the reviewer’s reflective and 

personal expertise, reasonable judgments are then made (Jones, 2004; Shank & 

Villella, 2004; Vetter, 2003). 

Although narrative reviews do not necessarily adhere to rigorous standards, 

results of the search, selection, and assessment procedures must meet 

the referees’ and editors’ criteria. It is important to keep in mind that when 

readers are not privy to a reviewer’s search methods, it is impossible to make 

judgments about the reviewer’s choices of studies. Readers value transparency 

and reproducibility (Collins & Fauser, 2005). 

Systematic Review of the Literature 

Systematic reviews are sometimes referred to as “best-evidence syntheses” 

or “practice-based research syntheses” (Dunst, 2009), particularly when 

applied to specific practice characteristics (Dunst & Trivette, 2009). This is a 

thorough, comprehensive, transparent, and unbiased review of the literature 

undertaken according to a clearly defined and systematic approach (Aveyard, 

2010; Neely et al., 2010). With the onset of the 21st century, systematic reviews 

have become increasingly more common (Altman, 2002), replacing narrative 

reviews and expert opinions or commentaries (Hemingway & Brereton, 2009). 

It is not unusual for a well conceptualized and relevant, in-depth, and interpretive 

research synthesis to contribute to one-fifth of a research paper’s overall 

word count. However, systematic reviews can be stand-alone research 

papers published in peer-review journals and their importance cannot be overemphasized 

(Dunne, 2011; Lucas & Cutspec, 2005). 

The process of integrating findings across many studies pertinent to a particular 

research question is an ideal first step toward according legitimacy and 

scholarliness to a research study (LeCompte, Klinger, Campbell, & Menke, 

2003). A persistent threat to the validity of any systematic review is publication 

bias, since some journal editors or reviewers tend to avoid publishing those 

studies with null or negative findings. This can render some reviews skewed 

toward positive findings (Berkeljon & Baldwin, 2009). To minimize this bias, 

reviewers search for and include “grey literature” (Berkeljon & Baldwin, 2009). 

Grey literature includes unpublished papers, census data, institutional or technical 

reports, working papers, surveys, government documents, conference 

proceedings, theses, and dissertations (Lucas & Cutspec, 2005). Research or 

subject librarians can be excellent sources of such non-published information 

(Sulouff, Bell, Briden, Frontz, & Marshall, 2005). It is important to keep in mind 

that grey literature may not be subjected to peer review or editorial control, 

hence the need for careful scrutiny (Hemingway & Brereton, 2009). 


Systematic reviews are lengthy processes that involve a focused crossdisciplinary 

search strategy with clearly stated criteria for inclusion and exclusion 

of the literature (Berkeljon & Baldwin, 2009). The process of collecting, 

reviewing, and presenting all available evidence pertaining to the topic or 

research question is not limited to randomized clinical trials (Neely et al., 

2010). A resource for reading high-quality systematic reviews, both in format 

and content, can be found in “Evidence-Based Communication Assessment 

and Intervention,” a peer-review journal that includes studies involving children 

with communication difficulties as well as speech and language disorders 

(Psychology Press). 

Meta-Analytic Review of the Literature 

Meta-analytic reviews, sometimes known as quantitative systematic 

reviews, provide a statistical approach to measure the effect size and impact 

of the aggregate studies relevant to the research question (Sun, Pan, & Wang, 

2010; Vetter, 2003). A meta-analysis, then, combines the data with similar 

properties – particularly if the multiple studies yield sufficient data (Aveyard, 

2010; Neely et al., 2010). Meta-analyses should also provide readers with 

perspective so that findings are interpreted in meaningful ways (Humphrey, 

2011). Every meta-analysis is based on an underlying systematic review, but 

not every systematic review leads to a meta-analysis (Neely et al., 2010). As 

noted in Figure 1, each meta-analytic review has a systematic review as its 

first stage. 

The second stage of a systematic review involves determining its appropriateness 

to calculate a pooled average across studies and, if so, then calculating 

and presenting the result. As a collection and integration of research studies 

to which a statistical formula was used to summarize the findings, metaanalyses 

calculates an average of the results from a body of literature 

(Aveyard, 2010; Neely et al., 2010). The two-stage process gives greater 

weight to those results that provide more information, hence weighted averages 

are an end outcome of meta-analytic reviews (Clarke, 2007). Given that 

meta-analytic reviews necessitate well-developed studies reflecting minimally 

sufficient experimental or quasi-experimental research with comparable 

samples of subjects, these are much more time-consuming and require 

considerable expertise, hence they are costlier to develop than systematic 

reviews (Larson, Pastro, Lyons, & Anthony, 1992). 

Not all studies yield the same type of evidence. When two or more types of 

evidence are examined within one systematic review, it is referred to as a 

mixed-method review. Meta-analytic reviews objectively inform us of the totality 

of evidence as well as provide sufficient justification for new research 

(Berkeljon & Baldwin, 2009). Assessing consistency of results and possibly settling 

controversies from conflicting studies are also reasons to perform a metaanalytic 

review. Moreover, meta-analytic reviews can yield good information 

356 Rhoades

Figure 1. Basic components of a systematic review with or without meta-analysis 

about potential strengths and weaknesses of intervention approaches (Odom, 

2009). However, meta-analyses do not typically provide detailed procedural 

information about specific practices (Odom, 2009). 

A meta-analytic review includes a final discussion section, whereby conclusions 

and recommendations are presented as based on the findings. There are 

several independent, nonprofit, international interdisciplinary organizations 

that focus on the provision of rigorous systematic reviews that include metaanalyses; 

these organized groups include the Cochrane Collaborative, the 

Campbell Consortium, and the Joanna Briggs Institute (Johnson, 2006). Their 

reviews, pertaining to behavioral, social, health, and educational interventions, 

are indexed in MEDLINE (Clark, 2007). However, these organizational 


esources may be of limited value for issues pertaining to speech and language 

interventions primarily due to their focus on randomized controlled trials that 

are not typically employed with children (Brackenbury, Burroughs, & Hewitt, 

2008), and they require a paid subscription. The Centre for Reviews and Dissemination 

(CRD) provides an international database of systematic reviews on 

health care interventions; this rapidly growing collection of systematic reviews 

is freely accessible to the public. While it does not yet include systematic 

reviews on educational interventions for children with hearing loss, CRD makes 

available reviews on hearing devices, Universal Newborn Hearing Screening, 

and incidence data as well as related issues. 

Problematic Literature Reviews 

A good review of the literature facilitates understanding a body of available 

research (De Los Reyes & Kazdin, 2008). As the process of reviewing the 

literature continues to evolve (Evans & Kowanko, 2000), some issues can negatively 

influence the quality of a literature review. Just as it is important that 

literature reviews delineate any problems inherent to the studies being 

reviewed, it is important that the process of conducting literature reviews be 

free of problematic issues. Poorly executed literature reviews tend to produce 

unreliable evidentiary findings. Manuscripts submitted for publication that 

have flawed literature reviews are no longer deemed worthy of peer-review 

journals (Randolph, 2009). Five problematic issues noted across some literature 

reviews are briefly highlighted here. 

Problem #1: Confusing “Best Practices” with “Evidence-Based Practices” 

“Best practice” is not the same thing as “evidence-based practice.” The 

term “best practice” has often been erroneously used to reflect the personal 

opinions of either experienced practitioners or biased interpretations of the 

literature (Schirmer & Williams, 2008). “Evidence-based practice” precedes 

“best practice” since it involves standardized data collection (Hayes, 2005). 

Restated, existing evidence informs practice. Empirical evidence rather than 

tradition, attitudes, beliefs, and experience drives those strategies employed 

by cross-cultural practitioners (Marschark, Spencer, Adams, & Sapere, 2011). 

For example, some authors consistently refer to pioneering practitioners of 

auditory-verbal therapy when describing some of the strategies often 

implemented in research studies targeting hearing loss and spoken language 

acquisition; this can mislead readers into thinking that the pioneers provided 

empirical evidence. 

Advocating for a particular strategy in a book that may be widely used by 

practitioners is not enough (Odom, 2009). Citing a body of literature, including 

a book that many may consider to be a “best practice,” is insufficient in making 

a case for evidence-based practice (Schirmer & Williams, 2008). Educational 

358 Rhoades

practice, such as early intervention, has evolved from a tradition-based 

approach to an evidence-based approach (Moore, 2008). Professional opinion 

is no longer recommended for promoting practices (Odom, 2009). For example, 

Marscharck and colleagues (2011) note that empirical support for many of the 

practices used in educating children with hearing loss remains limited. Clinical 

studies must be cited in order to promote evidence-based practice. A specific 

strategy or best practice intervention advocated by any author is now scientifically 

supported with clinical trials. 

It makes sense, then, that evidence-based practice mandates that the findings 

of multiple studies repeatedly or consistently demonstrate positive outcomes 

more often than not. For example, as briefly summarized elsewhere (Rhoades, 

2010), effectiveness of early intervention outcomes means that strategies can be 

applied on a practical level, i.e., “real world” settings, such as in the home or at 

school. The more families and children that are involved in research studies, 

the more likely the intervention can be considered effective. Only when an 

intervention is considered effective with large numbers of families and their 

children can it be embraced as being evidence-based (Zwarenstein, 2009), 

hence logically justified by practitioners. 

Problem #2: Overlooking Biases 

When a literature review reflects an undefined or poorly organized method of 

searching, it can result in a study of research that is not reflective of the true 

totality. Even if the reviewer provides a good critique of the selected studies, this 

can weaken the literature synthesis, resulting in a conclusion based on biased 

reviewer perceptions (Berkeljon & Baldwin, 2009; Johnson, 2006). McGauran 

and her colleagues (2010) present a concise summary of the many reporting 

biases encountered across intervention studies. These include: publication bias, 

time lag bias, duplicate publication bias, location bias, citation bias, language 

bias, and outcome reporting bias. Additionally, some reviewers may engage in 

reviewer or selection bias when they include low levels of evidence in their 

reviews rather than reviewing those studies reflecting higher levels of evidence 

(Rumrill & Fitzgerald, 2001). 

A good literature review exposes the biases of the many studies being 

reviewed. A concerted effort is made to avoid unprofessional behavior when 

selecting studies for inclusion, else the reviewer’s reliability and trustworthiness 

are suspect (Aveyard, 2010). However, as with any review, there are 

limitations that may or may not be acknowledged in the report. For example, 

given the current audit culture, it is not surprising that systematic reviews of 

the literature on early intervention for children with hearing loss have been 

compiled (e.g., CAHE Review Team, 2008). However, despite the extraordinarily 

good intentions of the review team, some significant studies 

pertaining to listening and spoken language intervention were omitted from 

the review process, either because the studies had not yet been published or 


the reviewers overlooked them. Data collection, extraction, analysis, and synthesis 

can be a year-long process, hence significant studies published during 

the year prior to publication may be excluded from the review. Given ongoing 

research, it is important that good literature reviews be executed with 

some degree of regularity. 

Problem #3: Frequently Using Secondary References 

Referring to authors who are not the original source increases the probabilities 

of inaccuracies, misrepresentations, and misinterpretations of the original 

study (Mudry, 2008; Paradis, 2006). Secondary sources are not acceptable for 

purposes of critical analyses; if used at all in a literature review, they should be 

used sparingly, such as when the original source cannot be located (Larson 

et al., 1992; Randolph, 2009). In addition to the need for reviewers to rely on 

primary references, it is also important that reviewers carefully read every 

reference cited in their own reviews as well as double check on the completeness 

and accuracy of their references. 

As an example of such inaccuracies, some authors in the field of hearing 

loss and spoken language acquisition cite Erber’s model (Erber & Hirsh, 1978) 

when discussing auditory skills, referring to it as a hierarchy of stages from 

detection through comprehension. In fact, his model was presented as an 

aggregate of concurrently developing auditory skills representing different 

levels of processing complexity. At present, however, there are different 

models pertaining to the auditory processing of language, depending on the 

specific question and evidence being reviewed (e.g., Davis & Johnsrude, 2003; 

Nelken, 2008; Obleser & Eisner, 2008; Werner, 2007). An equally glaring and 

somewhat classic example of this problem occurs when authors first cite 

original researchers for validating a particular strategy or evidentiary finding 

in an earlier paper, and then later cite themselves when referring to the same 

particular strategy or evidentiary finding, thus potentially misleading readers 

into thinking they provided the evidence for the strategy. 

Problem #4: Relying on a Limited Database 

Researchers may be familiar with MEDLINE and primarily rely on this 

database because it minimizes false-positive results (Shojania & Bero, 2001). 

However, less than half of all relevant studies may be found here (Hemingway 

& Brereton, 2009). A variety of databases should be employed if readers are 

to benefit from a comprehensive review of the literature. Additionally, it is 

crucial to extract information on cross-disciplinary and cross-cultural levels. 

For example, children with hearing loss are children first. Effective practitioners 

first understand the rates or characteristics of typical family or child 

development before learning about the atypical family or child. If the literature 

search is an in-depth one that cuts across different disciplines, then previously 

360 Rhoades

unnoticed relationships and patterns between studies can be brought to 

readers’ attention (Lucas & Cutspec, 2005). 

Problem #5: Poorly Critiquing the Studies 

Reasons for faulty reviews have to do with poor research design, statistical 

complexities, and the peer review process. According to Altman (2002), a 

significant number of statistical errors have been found in varied systematic 

reviews. Methodological errors have often persisted from year to year. 

Reviewers may uncritically accept other researchers’ findings and interpretations 

as valid, or they may not consider contrary findings and alternative 

interpretations when synthesizing the aggregate studies (Randolph, 2009). 

Assumptions about the comparability of study samples and interventions 

are to be avoided. Readers can minimize this by bringing errors to editors’ 

attention, and editors can then publish corrections or retractions. Ultimately, 

however, the fault of poor research lies with authors rather than editors 

(Altman, 2002). 

Process of Developing a Good Literature Review 

A literature review is a process that involves a series of carefully executed and 

time-consuming steps (Neely et al., 2010). These are based on a peer-reviewed 

protocol so that the process can be replicated when necessary (Hemingway & 

Brereton, 2009). While authors developing narrative reviews do not necessarily 

adhere to all the steps critical for a systematic review, readers will better 

appreciate any review that involves clearly articulated steps undertaken by 

authors. Transparency and studious avoidance of bias are critical for any review 

of the literature. 

Define the Topic or Research Question 

The initial step of any literature review involves defining the specific and 

unambiguous statement of review objectives or research question (Neely et al., 

2010). A good research question acts as a guide, clearly providing focused 

structure for the literature review process (Aveyard, 2010). Formulation of an 

appropriate research topic enables the reviewer to develop a plan of action for 

the literature search. 

Identify the Relevant Information: Inclusion/Exclusion Criteria and Keywords 

The second step of the review process involves establishing inclusion and 

exclusion criteria based on the variables of interest within the research question. 

This means knowing the characteristics of the subject population as well 

as variables relevant to the objective or research question. These variables are 


igorously used to select studies for the review process (Hemingway & 

Brereton, 2009). The specifics of each study need to fit the research question. 

The reviewer also needs to identify all relevant information to be used in the 

literature search. Keywords are central to the search for studies considered 

relevant to the topic or research question studies; keywords are used to search 

different databases (Aveyard, 2010). The lexicon employed by the reviewer 

plays a crucial role in the literature search. The use of controlled vocabularies 

and natural language can be enhanced with a thesaurus in the search process 

(Lucas & Cutspec, 2005). Moreover, the operationalization of definitions can 

facilitate reader comprehension of the constructs that bear on the study. Interestingly, 

identifying the variables, keywords, and definitions can result in revisions 

prior to actual analysis of the aggregate studies. 

Conduct the Literature Search 

Logically, the next step of the review process is to conduct the search with 

the identified keywords. The search process involves a combination of many 

search tactics that include hand searching key journals and books, accessing 

the many electronic literature databases, investigating reference lists, and scanning 

the Internet via multiple search engines, the latter likely to also include 

grey literature (Hemingway & Brereton, 2010; Lucas & Cutspec, 2005). This 

search is cross-disciplinary in that studies from various specializations are 

included. For example, there are many journals within the broad disciplines 

of special education, allied health, and medicine as well as family-based and 

child-based psychology that may be relevant to some topics involving children 

with hearing loss. 

Reviewers engage in careful record keeping of this labor-intensive and complex 

search process, partly to ensure readers of its breadth and depth. Graphic 

organizers, such as flowcharts, may facilitate reader understanding of how the 

published and unpublished studies were found, and then included or 

excluded as part of the literature search (Berkeljon & Baldwin, 2009). 

A careful literature search necessitates the use of many search engines, electronic 

databases, and websites; these include non-English ones to minimize 

selection, language, and publication biases (Hemingway & Brereton, 2009). 

Although most databases necessitate paid subscriptions but do provide article 

abstracts, others offer access to full text published articles at no charge to the 

public. For studies relevant to families and their children with hearing loss, some 

frequently used and highly relevant electronic databases are listed in Figure 2. 

Screen All and Exclude the Irrelevant Studies 

When all papers are compiled and abstracts are read, the next step is to identify 

those studies potentially relevant to the research question (Hemingway & 

Brereton, 2009; Neely et al., 2010). After the studies are screened and the irrelevant 

362 Rhoades

Figure 2. Selected list of electronic databases 

ones excluded, relevant papers are screened again to ensure consistent relevance 

to the research question and all identified variables. 

Scrutinize the Relevant Studies 

The next step occurs when remaining studies, the full-text relevant papers, 

are carefully read for their details and eligibility. At this point, two independent 

reviewers can ensure that those studies selected for inclusion are consistent 

with the research question and protocol. This is when assessment of each 

study begins and the data extracted from the selected studies are collected in 

some organized fashion. Using a critical appraisal framework, the methodological 

quality, relevance, and credibility of each paper is determined. Based on 

this qualitative level of assessment, all biases are noted and poor quality studies 

are excluded. 

Extract Data and Develop Graphic Organizers 

Remaining studies are determined to be relevant, credible, and essentially 

of sound methodological design. Reported findings from these studies are 

extracted onto a data extraction form. For this tabulated data, visual clarifiers 

can be developed to facilitate knowledge of the similarities and differences 

between the relevant studies. Graphic organizers summarize the important 

variables extracted across studies. When data are extracted for analysis and 

synthesis, the different studies may vary considerably. It is at this point that 

the determination is made as to whether a meta-analysis is appropriate or not. 


If the aggregate subjects or studies are few in number or if the studies vary 

considerably across variables, then a meta-analysis is not warranted. If the 

reviewer determines that the aggregate studies do not provide sufficient 

evidence, then it is important to present that finding however difficult it may 

be to publish (Alderson & Roberts, 2000). 

Synthesize the Findings 

Again, with two independent reviewers, findings from each study are 

aggregated to produce a “bottom line” on the clinical effectiveness, feasibility, 

appropriateness, and meaningfulness of the intervention (Hemingway & 

Brereton, 2009). The pooled findings are referred to as evidence synthesis. If 

the studies involved qualitative data or did not include a large enough body 

of quantitative data, then a meta-synthesis is provided in the literature 

review. However, if the studies involved sufficient and homogenous quantitative 

data, then a meta-analysis is conducted (Hemingway & Brereton, 2009). 

Develop Conclusions and Recommendations 

The last part of a good literature review, regardless of whether it is qualitative 

or quantitative, provides an impartial summary description of the evidence 

generated by each relevant and credible study. Findings discuss issues such as 

the quality and heterogeneity of the included studies, the likely impact of bias, 

and the chance and applicability of the findings. The interpretive reporting of 

these multiple studies, both analysis and synthesis, minimizes biases and provides 

insightful, explicit judgments that may facilitate new directions in 

thought, both for practice and research (Hemingway & Brereton, 2009). 

Most literature reviews typically warrant improvement and updating at 

least every few years, if not more frequently, depending on the number of 

studies generated since the last exhaustive summary of the literature. It is 

important that authors adhere to the standards and guidelines for reviewing 

the literature. Although all studies have limitations or flaws, these studies can 

provide important information (Hemingway & Brereton, 2009). However, 

some systematic reviews have been found to be more wanting than others 

are, hence not as reliable or as effective as other literature reviews. Thus, it is 

important that prospective authors develop awareness of the problematic 

issues noted in the reviews. 

Conclusion 

Although some literature reviews can be more narrowly focused than 

others, all good literature reviews contain a clearly defined research question, 

rigorous criteria for identifying studies relevant to the question, a focused 

review of at least all published studies that meet clearly stated criteria, a 

364 Rhoades

clearly documented and well justified methods sections, an in-depth critical 

analysis and synthesis of the aggregate studies, and a final discussion section 

that includes conclusions and recommendations. 

For example, two recent reviews on language intervention with young 

hearing children have two different research questions, hence different outcomes. 

The first is a meta-analytic review (Roberts & Kaiser, 2011) that 

evaluated the effectiveness of parent-implemented language interventions 

on the language skills of young children with primary and secondary language 

impairments. Effect sizes for each of 18 studies were calculated for 

seven language variables; results indicated that such interventions had a 

significant, positive impact on the language skills. The second review 

(Petersen, 2011) was systematic in nature, focusing on those research papers 

published since 1980 that assessed outcomes of narrative-based language 

interventions for children with language delays; results indicated this type 

of language intervention to be an emerging stage of evidence warranting 

further investigation. 

Good literature reviews should indicate whether the evidence for select 

listening strategies is anecdotal or clinical in nature, making clear distinctions 

between best practice and evidence-based practice. Authors should aim for 

unbiased reporting, use of primary references, and a focused review of at 

least all published studies pertaining to the topic. Readers are always 

informed of the steps taken across the literature review process. All good 

reviews of the literature represent the starting point for creating new knowledge, 

bringing new insights to readers because certain information is view in 

the wider context of other information. The ongoing practice of self-reflection 

and critical examination, although sometimes painful, can ultimately serve to 

improve practitioners’ delivery of varied models of intervention that, in turn, 

benefits families of children with hearing loss. 

Acknowledgement 

Portions of this commentary were originally published in The Volta Review, 

Volume 111, Issue 1. It has been expanded to include problematic literature 

reviews and is reprinted in its entirety here. 

References 

Alderson, P., & Roberts, I. (2000). Should journal publish systematic reviews 

that find no evidence to guide practice? Examples from injury research. 

British Medical Journal, 320(7231), 376–377. 

Altman, D. G. (2002). Poor-quality medical research: What can journals do? 

Journal of American Medical Association, 287, 2765–2767. 

Aveyard, H. (2010). Doing a literature review in health and social care: A practical 

guide, 2nd ed. Berkshire, England: Open University Press. 


Baum, A. C., & McMurray-Schwarz, P. (2007). Research 101: Tools for reading 

and interpreting early childhood research. Early Childhood Education Journal, 

34(6), 367–370. 

Berkeljon, A., & Baldwin, S. A. (2009). An introduction to meta-analysis for 

psychotherapy outcome research. Psychotherapy Research, 19(4–5), 511–518. 

Brackenbury, T., Burroughs, E., & Hewitt, L. E. (2008). A qualitative examination 

of current guidelines for evidence-based practice in child language 

intervention. Language, Speech & Hearing Services in Schools, 39(1), 78–88. 

CAHE Review Team. (2008). A systematic review of the literature on early intervention 

for children with a permanent hearing loss, Volume I. Brisbane, Australia: 

Centre for Allied Health Evidence, University of South Australia. 

Clarke, M. (2007). The Cochrane collaboration and the Cochrane library. 

Otolaryngology-Head and Neck Surgery, 147, S52–S54. 

Collins, J. A., & Fauser, C. J. M. (2005). Balancing the strengths of systematic 

and narrative reviews. Human Reproduction Update, 11(2), 103–104. 

Davis, M. H., & Johnsrude, I. S. (2003). Hierarchical processing in spoken 

language comprehension. The Journal of Neuroscience, 23(8), 3423–3431. 

De Los Reyes, A., & Kazdin, A. E. (2008). When the evidence says, "Yes, no, 

and maybe so": Attending to and interpreting inconsistent findings among 

evidence-based interventions. Current Directions in Psychological Science, 

17(1), 47–51. 

Dunne, C. (2011). The place of the literature review in grounded theory 

research. International Journal of Social Research Methodology, 14(2), 111–124. 

Dunst, C. J. (2009). Implications of evidence-based practices for personnel 

preparation development in early childhood intervention. Infants & Young 

Children, 22(1), 44–53. 

Dunst, C. J., & Trivette, C. M. (2009). Using research evidence to inform and 

evaluate early childhood intervention practices. Topics in Early Childhood 

Special Education, 29(1), 40–52. 

Dunst, C. J., Trivette, C. M., & Cutspec, P. A. (2002). Toward an operational 

definition of evidence-based practices. Centerscope, 1(1), 1–10. 

Erber, N. P. & Hirsh, I. (1978). Auditory training. In H. Davis and S. R. 

Silverman (Eds.) Hearing and Deafness (pp. 358–361). New York: Holt, 

Rinehart & Winston. 

Evans, D., & Kowanko, I. (2000). Literature reviews: Evolution of a research 

methodology. The Australian Journal of Advanced Nursing, 18(2), 33–38. 

Grady, D., & Hearst, N. (2007). Utilizing databases. In S. B. Hulley, S. R. 

Cummings, W. S. Brown, D. Grady, & T. B. Newman (Eds.), Designing 

clinical research, 3rd edition (pp. 207–224). Philadelphia, PA: Lippincott Williams 

&Wilkins. 

Hayes, R. A. (2005). Build your own best practice protocols. Hoboken, NJ: 

John Wiley. 

Hemingway, P., & Brereton, N. (2009). What is a systematic review? Retrieved 

November 30, 2010, from www.whatisseries.co.uk. 

366 Rhoades

Humphrey, S. E. (2011). What does a great meta-analysis look like? Organizational 

Psychology Review, 1(2), 99–103. 

Johnson, C. J. (2006). Getting started in evidence-based practice for childhood 

speech-language disorders. American Journal of Speech-Language Pathology, 

15(1), 20–35. 

Jones, K. (2004). Mission drift in qualitative research, or moving toward a 

systematic review of qualitative studies, moving back to a more systematic 

narrative review. The Qualitative Report, 9(1), 95–112. 

Larson, D. B., Pastro, L. E., Lyons, J. S., & Anthony, E. (1992). The systematic 

review: An innovative approach to reviewing research. Washington, DC: Office 

of Disability, Aging and Long-term Care Policy; Office of the Assistant 

Secretary for Planning and Evaluation; U.S. Department of Health and 

Human Services. 

LeCompte, M. D., Klinger, J. K., Campbell, S. A., & Menke, D. W. (2003). 

Editor’s introduction. Review of Educational Research, 73(2), 123–124. 

Lucas, S. M., & Cutspec, P. A. (2005). The role and process of literature 

searching in the preparation of a research synthesis. Centerscope, 3(3), 

1–26. 

Marschark, M., Spencer, P. E., Adams, J., & Sapere, P. (2011). Evidence-based 

practice in educating deaf and hard-of-hearing children: teaching to their 

cognitive strengths and needs. European Journal of Special Needs Education, 

26, 3–16. 

McGauran, N., Wieseler, B., Kreis, J., Schüler, Y-B., Kölsch, H., & Kaiser, T. 

(2010). Reporting bias in medical research—a narrative review. Trials, 

11(37), 1–15. 

Moore, T. (2008). Early childhood intervention: Core knowledge and skills. 

CCCH Working Paper 3 (November 2008). Parkville, Victoria, UK: Centre for 

Community Child Health. 

Mudry, A. (2008). Never trust secondary references: Examples from the early 

history of myringotomy and grommets. International Journal of Pediatric 

Otorhinolaryngology, 72, 1651–1656. 

Neely, J. G., Magit, A. E., Rich, J. T., Voelker, C. C. J., Wang, E. W., 

Paniello, R. C., et al. (2010). A practical guide to understanding systematic 

reviews and meta-analyses. Otolaryngology-Head and Neck Surgery, 

142, 6–14. 

Nelken, I. (2008). Processing of complex sounds in the auditory system. 

Current Opinion in Neurobiology, 18, 1–5. 

Obleser, J. & Eisner, F. (2008). Pre-lexical abstraction of speech in the auditory 

cortex. Trends in Cognitive Science, 13(1), 14–19. 

Odom, S. L. (2009). The tie that binds: Evidence-based practice, implementation 

science, and outcomes for children. Topics in Early Childhood Special 

Education, 29(1), 53–61. 

Paradis, M. (2006). More belles infidèles – or why do so many bilingual studies 

speak with forked tongue? Journal of Neurolinguistics, 19, 195–208. 


Petersen, D. B. (2011). A systematic review of narrative-based language intervention 

with children who have language impairment. Communication 

Disorders Quarterly, 32(4), 207–220. 

Randolph, J. J. (2009). A guide to writing the literature dissertation review. 

Practical Assessment, Research & Evaluation, 14(13), 1–13. 

Rhoades, E. A. (2010). Evidence-based auditory-verbal practice. In E. A. 

Rhoades & J. Duncan (Eds.), Auditory-verbal practice: Toward a family-centered 

approach (pp. 23–52). Springfield, IL: Charles C. Thomas. 

Roberts, M. Y., & Kaiser, A. P. (2011). The effectiveness of parentimplemented 

language interventions: A meta-analysis. American Journal of 

Speech-Language Pathology, 20, 180–199. 

Rumrill, P. D., & Fitzgerald, S. M. (2001). Using narrative literature reviews to 

build a scientific knowledge base. Work: A Journal of Prevention, Assessment, 

and Rehabilitation, 16(2), 165–170. 

Schirmer, B. R. & Williams, C. (2008). Evidence-based practices are 

not reformulated best practices. Communication Disorders Quarterly, 29(3), 

166–168. 

Shank, G. & Villella, O. (2004). Building on new foundations: Core principles 

and new directions for qualitative research. The Journal of Educational 

Research, 98(1), 46–55. 

Shojania, K. G., & Bero, L. A. (2001). Taking advantage of the explosion of 

systematic reviews: An efficient MEDLINE search strategy. Effective Clinical 

Practice, 4(4), 157–162. 

Sulouff, P., Bell, S., Briden, J., Frontz, S., & Marshall, A. (2005). Learning about 

grey literature by interviewing subject librarians: A study at the University 

of Rochester. College and Research Libraries News, 66, 510–515. 

Sun, S., Pan, W., & Wang, L. L. (2010). A comprehensive review of effect size 

reporting and interpreting practices in academic journals in education and 

psychology. Journal of Educational Psychology, 102(4), 989–1004. 

Vetter, N. (2003). What is a clinical review? Reviews in Clinical Gerontology, 

13, 103–105. 

Werner, L. A. (2007). Issues in human auditory development. Journal of 

Communication Disorders, 40, 275–283. 

Zwarenstein, M. (2009). What kind of randomized trials do we need? 

Canadian Medical Association Journal, 180(10), 998–1000. 

368 Rhoades

The Volta Review - Alexander Graham Bell Association

Create successful ePaper yourself

Delete template?

Save as template?