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The Journal of Deaf Studies and Deaf Education logoLink to The Journal of Deaf Studies and Deaf Education
. 2023 Jan 6;28(2):189–200. doi: 10.1093/deafed/enac050

Home Literacy Experiences and Shared Reading Practices: Preschoolers With Hearing Loss

Jean L DesJardin 1,✉, Carren J Stika 2, Laurie S Eisenberg 3, Karen C Johnson 4, Dianne Hammes Ganguly 5, Shirley C Henning 6
PMCID: PMC10373947  PMID: 36617254

Abstract

Home literacy experiences and observed parent and child behaviors during shared book reading were investigated in preschool-age children with hearing loss and with typical hearing to examine the relationships between those factors and children’s language skills. The methods involved parent-reported home literacy experiences and videotaped parent–child dyads during shared book reading. Children’s language skills were tested using the Preschool Language Scale-4. The results indicated significant differences between groups for home literacy experiences and observed parent and child behaviors. Parents of children with hearing loss were found to read more frequently to their children than parents of children with typical hearing, yet scored lower for literacy strategies and teaching techniques compared to parents of children with typical hearing. Children with hearing loss scored lower in interactive reading behaviors compared to children with typical hearing. For children with hearing loss, frequency of book reading and child interactive reading behaviors were strong predictive factors for children’s language skills. These results suggest that families of children with hearing loss would benefit from professional support as they read storybooks to their children. Similarly, children with hearing loss should be encouraged to be more interactive during shared book reading.

The preschool years are a significant time in a young child’s life for developing fundamental skills in language and early learning prior to kindergarten. Children with typical hearing (TH) who enter kindergarten with strong language skills demonstrate higher school achievement in later grades than children with delayed language skills (Catts, Compton, Tomblin, & Bridges, 2012; Duncan et al., 2007; Hong et al., 2021). Moreover, these children have a higher probability of entering college (Blanden, 2006). Similar trends hold true for preschool-age children with mild to profound sensorineural hearing loss (HL), as language skills positively relate to school readiness skills (Harrington, DesJardin, & Shea, 2010), emergent literacy abilities (Campbell et al., in review; DesJardin, Ambrose, & Eisenberg, 2009; DesJardin et al., 2014; Easterbrooks, Lederberg, Miller, Bergeron, & Connor, 2008; Nittrouer, Caldwell, Lowenstein, Tarr, & Holloman, 2012), and later school-age outcomes (Tomblin et al., 2020). However, despite the benefits of current hearing aid technology, large variability exists in language skills for preschool- to kindergarten-age children who use hearing aids (Koehlinger, Owe-Van Horne, & Moeller, 2013; Tomblin et al., 2015; Werfel, Reynolds, & Fitton, 2022). At the entry to kindergarten, children with HL who demonstrate significant language delays may also have difficulty reaching the expected early literacy and academic milestones in current early childhood classrooms (Jin et al., 2020).

An enriched language-learning environment offers young children the opportunity to learn language through multiple interactions with caregivers in their homes (DeMir-Lira, Applebaum, Goldin-Meadow, & Levine, 2019; Mol & Bus, 2011). In particular, home literacy experiences (HLEs), including shared storybook reading (SBR), have been highlighted as a language-rich opportunity that supports language and early literacy skills in young children with TH (Barnes & Puccioni, 2017; Blewitt & Langan, 2016; Dickinson, Griffith, Golinkoff, & Hirsh-Pasek, 2012; Grollig, Cohrdes, Tiffin-Richards, & Schroeder, 2019) and children with HL (Aram, Most, & Mayafit, 2006; DesJardin, 2009; DesJardin et al., 2014; DesJardin et al., 2017; DesJardin & Ambrose, 2010; DesJardin & Eisenberg, 2007). Despite this generally positive association, much variability exists in home literacy practices for populations of young children with HL. As an example, a recent study reported no significant differences in the frequency of book reading per week by parents to their young children with TH compared to parents of children with HL, but parental groups varied in terms of the quality of observed book reading behaviors (e.g., engagement, interactive reading strategies) (DesJardin et al., 2017). Children may also play an important role in SBR interactions (e.g., child engagement) (Aram et al., 2006; Reynolds & Werfel, 2020). Child linguistic initiatives such as talking about characters in the book or asking questions support children’s comprehension. As such, the contributions that both parents and children play in the SBR experience warrant prospective investigation to determine their respective contributions to children’s language outcomes.

 

Shared Book Reading and Children With TH

The National Association of Education for Young Children (NAEYC, 2012) highlights interactive SBR (e.g., parents asking open-ended questions and expanding on children’s linguistic attempts) as one of the most important activities that can benefit young children’s development. Both the quantity (Farrant & Zubrick, 2011; Grollig et al., 2019) and quality (Barnes & Puccioni, 2017; Edwards, Sheridan, & Knoche, 2008) of interactive reading have been shown to advance children’s language and early learning skills in young children with TH (Farrant & Zubrick, 2013; Sénéchal & Le Fevre, 2014; Whitehurst et al., 1988). Parents who read often with their young children are more likely to encourage child engagement (e.g., elaborates on child’s ideas) and utilize literacy strategies (e.g., open-ended questioning, points to pictures; Cleave, Becker, Curran, Van Horne, & Fey, 2015; Sénéchal & Le Fevre, 2014). As a result, these children tend to enter kindergarten more prepared in the areas of language and early literacy skills than children who do not have those same SBR experiences (Barnes & Puccioni, 2017). In fact, parent book reading utterances predict preschoolers’ later vocabulary and reading abilities even after controlling for child language contributions to book reading interactions and parent socioeconomic background (Demir-Lira et al., 2019). Moreover, parents trained to use specific literacy strategies tailored to their children’s language abilities can further support language development in young children with TH (Roberts, Curtis, Stone, & Hampton, 2019). Both the quantity and quality of SBR are important factors that contribute to language development in preschool-age children.

Shared Book Reading and Children With HL

Parental report and observed SBR behaviors in younger children provide some understanding about how SBR can support language development in young children with HL (Aram et al., 2006; Cruz, Quittner, Marker, & DesJardin, 2013; DesJardin et al., 2014; DesJardin et al., 2017; DesJardin & Eisenberg, 2007; Dirks & Wauters, 2018; Reynolds & Werfel, 2020; Zaidman-Zait & Dromi, 2007). First, research findings suggest that parents of young children with HL read similar amounts of time per week to their children as parents of children with TH (DesJardin et al., 2014; DesJardin et al., 2017; Reynolds & Werfel, 2020). Moreover, the sheer amount of time reading per week (>15 min per day rather than <15 min per day) can further increase language and literacy skills for young children with HL (Campbell et al., in review; DesJardin et al., 2014; DesJardin et al., 2017). Secondly, in terms of the quality of SBR interactions, parents’ intuitive parenting skills and use of specific strategies can support language learning in populations of young children with HL (DesJardin et al., 2014; Swanwick & Watson, 2007). Overall, parents of preschool children with HL demonstrate intuitive parenting skills (Koester, 1992) that support their child’s interaction with storybooks regardless of mode of communication (DesJardin et al., 2017; Swanwick & Watson, 2007). Specifically, parents of young children with HL remain close in proximation to the child and storybook and perform reciprocal exchanges and shared meaning with their children. DesJardin and her colleagues further refined parental strategies and found that mothers’ use of higher-level facilitative language techniques (i.e., recasts and open-ended questions), literacy strategies (e.g., posing and eliciting questions), and teaching techniques (e.g., soliciting predictions about the story) supports language skills in groups of young children with HL (DesJardin et al., 2009; DesJardin et al., 2014; DesJardin, Ambrose, & Eisenberg, 2011; DesJardin & Eisenberg, 2007). Although parents of toddlers with HL who use hearing aids report more difficulty reading to their children compared to parents of toddlers with TH (DesJardin et al., 2014, 2017; Swanwick & Watson, 2007; Zaidman-Zait & Dromi, 2007), parents of toddlers with HL demonstrate a greater number of literacy strategies (e.g., pointing to and labeling pictures) and teaching techniques (e.g., elaborating on child ideas) during SBR than parents of toddlers with TH (DesJardin et al., 2014). Furthermore, DesJardin et al. (2017) found that parents of 36-month-old children with HL demonstrate less interactive reading strategies during SBR than parents of 36-month-old children with TH. Intentionally teaching parents interactive reading strategies to their toddlers can increase parents’ use of strategies over time (Dirks & Wauters, 2018) and these similar interactive reading strategies can positively relate to language skills for children with HL ranging in age from two- to three years (DesJardin et al., 2017). Although findings from these studies suggest parents’ quantity and quality of SBR relate to children’s language skills, it could be the case that as children get older, their language skills may also influence the quantity of reading and the quality of strategies that parents provide to their child during SBR.

Children’s interactive role during SBR may also influence parents’ behaviors. Research has shown that “the ongoing relationship between parent and child is not static but is continually changing and evolving” (Spiker, Boyce, & Boyce, 2002, p. 37). Moreover, parents and children influence each other in a bidirectional relationship (Bell & Harper, 1981; Kuczynski, 2003; Trevarthen & Aitkin, 2001). Indeed, the active role that children play during SBR appears to support language skills in children with TH (Blewitt & Langan, 2016; Mol, Bus, de Jong, & Smeets, 2008). Specifically, children’s sustained engagement and active participation positively influence expressive language development for young children with TH (Crain-Thoreson & Dale, 1992; Trivette, Dunst, & Gorman, 2010). Similarly, greater responsiveness by children to their parents’ questions during SBR interactions has a positive effect on language learning (Sénéchal, 1997).

Parental engagement and SBR strategies may not be the only factors that positively influence children’s language abilities. In the longitudinal investigation of young children with HL by DesJardin et al. (2017), parents’ reports of their child’s enjoyment during SBR at 12 months of age were positively related to child language outcomes at 36 months. In the same study, however, 12-month-old children with HL demonstrated less engagement (i.e., sustained interest) during observed SBR interactions compared to 12-month-old children with TH. By the age of 36 months, children with HL demonstrated less guided reading behaviors, such as pointing to and commenting on pictures in the book, compared to 36-month-old children with TH. Similar findings were found for 24-month-old children with HL in a different study (Zaidman-Zait & Dromi, 2007), whereby children with HL demonstrated less involvement behaviors and produced less spontaneous words compared to their 24-month-old peers without HL. Recent studies have noted that parents of preschool-age children with HL report lower engagement and interest in books than children with TH (Reynolds & Werfel, 2020). Yet, parents’ reports of child engagement with books were significantly related to children’s emergent literacy skills (Reynolds & Werfel, 2020). It is also possible that children’s language levels influence the ways in which parents interact with their children during SBR. Thus, disentangling parent and child observed behaviors during SBR would help clarify the role that each partner plays in promoting the child’s language development.

This is the first study to explore the relationships between home literacy practices (frequency of reading, observed parent–child behaviors during SBR) and language skills in preschool-age children with HL who utilize hearing aids. Comparing home literacy factors to a TH control group will identify whether HL contributes to parent and child SBR behaviors and children’s total language scores. Relationships will be explored between HLE factors, including parent observed SBR behaviors, and children’s total language skills for children with HL. With a greater understanding of the HLE factors, including observed parent and child SBR behaviors, professionals serving children with HL who utilize hearing aids can collaborate with parents to support their children’s language skills through SBR activities prior to entering kindergarten.

Purpose of the Present Study

The primary aim of this study was to investigate the quantity (e.g., frequency of shared reading, child enjoyment) and quality (both parent and child behaviors) of shared book reading in preschool-age children with and without HL. Correlational and regression analyses were used to explore the precise mechanisms (parent and/or child behaviors) that potentially impact the language skills of children with HL prior to entering kindergarten. Thus, this study addressed the following research questions:

  1. Are there group differences between parents of preschool-age children with and without HL in terms of parents’ reported HLEs (e.g., frequency of book reading) and observed parent and child behaviors during SBR?

  2. Are there significant relationships between parents’ reported HLE (e.g., frequency of book reading), observed parent and child SBR behaviors, and children’s language skills for children with HL who utilize hearing aids?

  3. What parent HLE and observed behaviors and child observed behaviors influence language skills in preschool-age children with HL who utilize hearing aids?

Methods

Participants

As part of a longitudinal prospective study (Stika et al., 2015), a culturally diverse sub-sample of 36 parents (35 mothers and one father) and their children with bilateral mild-to-severe HL was included in the present investigation, incorporating a cross-sectional analysis. Forty-nine parents (48 mothers and 1 father) and their children of similar age with TH were enrolled for comparison purposes. The original study sample consisted of 39 parents and their children with HL and 49 parents and children with TH. Three parents and their children with HL were not included in the present analysis, as they were not able to attend the SBR session. The larger study (Stika et al., 2015) was conducted to investigate multi-dimensional aspects of child development (e.g., psychosocial, language, adaptive behavior) and family variables that contribute to select child developmental outcomes (e.g., maternal self-efficacy and executive functioning, and parenting stress). All children were recruited through two pediatric hearing research clinics. Both sites received Internal Review Board Approval for this study. Inclusion criteria for both groups of children included no known secondary disability and a primarily English-speaking home. Inclusion criteria for the children with HL included confirmed permanent HL bilaterally, with a four-frequency pure tone average (PTA) threshold of 20 to 89 dB HL in the better ear (PTE-BE). The TH group showed hearing within normal limits bilaterally.

Parents

As shown in Table 1, no significant differences were evident between parent groups in terms of parent age, marital status, family income, and education level. Parents were primarily mothers, married, approximately 36 years old, spoke English, and had a college education. Although the study sample was predominately White, both parent groups were diverse relative to ethnicity, with 25.0% of the parents of children with HL and 12.2% of the parents of children with TH identified as Hispanic or Latino.

Table 1.

Demographic characteristics of parent

Parent characteristics Hearing loss n = 36 Typical hearing n = 49
Age in years M (SD)
range in years 		36.1 (6.35)
22.8–51.3 		35.5 (5.62)
22.3–45.9
Gender n (%)
Father
Mother		 1 (1.0%)
35 (99.0%)		 1 (1.0%)
48 (99.0%)
Race n (%)
White
African American
Asian
Mixed race
Not reported		 29 (80.6.5%)
2 (5.6%)
3 (8.3%)
2 (5.6%)
0 (.0%)		 41 (85.4%)
1 (2.1%)
3 (6.3%)
3 (6.3%)
1 (2.0%)
Ethnicity n (%)
Hispanic
Non-Hispanic		 9 (25.0%)
27 (75.0%)		 6 (12.2%)
43 (87.8%)
Highest education level n (%)
<High school
Some college
College degree
Postgraduate		 3 (8.3%)
11 (30.6%)
17 (47.2%)
5 (13.9%)		 1 (2.0%)
3 (6.1%)
24 (48.0%)
10 (20.4%)
Employment status n (%)
Full-time
Part-time
Not working
Student		 20 (55.6%)
4 (11.1%)
11 (30.6%)
1 (2.8%)		 20 (40.9%)
11 (22.4%)
15 (30.6%)
3 (6.1%)
Household annual income n (%)
<15,000
$15–29,000
$30–49,000
$50–74,999
$75–100,000
>$100,000		 1 (2.8%)
3 (8.3%)
5 (13.9%)
8 (22.3%)
9 (25.0%)
10 (27.8%)		 4 (8.2%)
4 (8.2%)
4 (8.1%)
8 (16.3%)
12 (24.5%)
17 (34.7%)
Marital status n (%)
Married
Single (never married).
Divorced
Living w/Partner		 26 (72.2%)
5 (13.9%)
4 (11.1%)
1 (2.8%)		 40 (81.6%)
4 (8.2%)
2 (4.1%)
3 (6.1%)
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Children

As shown in Table 2, both groups of children are equated on age, gender, race, and ethnicity. Both groups of children were approximately 47 months old. Parents reported that eight children with HL (22.2%) and 10 children with TH (20.4%) identified as Hispanic or Latino. Seven children with HL (19.4%) and 10 children with TH indicated that, although English was their first language, a second language was also spoken in the home. Approximately 11 (30.6%) children with HL and 21 (42.9%) children with TH attended some form of preschool setting.

Table 2.

Demographic characteristics of children

Children characteristics Hearing loss n = 36 Typical hearing n = 49
Age in months M (SD)
range in months 		47.4 (3.28)
37.0–50.1 		47.9 (2.41)
46.9–50.4
Gender n (%)
Male
Female		 19 (52.8%)
17 (47.2%)		 27 (55.1%)
22 (44.9%)
Race n (%)
White
African-American
Asian
Mixed race		 29 (80.6%)
2 (5.6%)
3 (8.3%)
2 (5.6%)		 42 (85.7%)
1 (2.0%)
3 (6.1%)
3 (6.1%)
Ethnicity n (%)
Hispanic
Non-Hispanic		 8 (22.2%)
28 (77.7%)		 10 (20.4%)
39 (79.6%)
Second language in home n (%)
Yes
No		 7 (19.4%)
29 (80.6%)		 10 (20.4%)
39 (79.6%)
Rating of child health n (%)
Excellent
Very good
Good		 14 (38.9%)
15 (41.7%)
6 (16.7%)		 28 (57.1%)
17 (34.7%)
4 (8.1%)
Preschool experience
Yes
No		 11 (30.6%)
25 (69.4%)		 21 (42.9%)
28 (57.1%)
Intervention/IEP
Yes
No		 29 (80.6%)
7 (19.4%)		 3 (6.1%)
46 (93.9%)
Preschool Language Scale (PLS-4)
Total Standard Score M (SD)
range 		94.58 (20.01)
50–127 		112.55 (13.48)**
80–141
Newborn hearing screening n (%)
Yes
No		 31 (86.1%)
5 (13.9%)
Cause of hearing loss unknown n (%) 26.0 (72.2%)
Hearing loss n (%)
Mild (PTA-4 = 21–39 dB)
Moderate (PTA-4 = 40–54 dB)
Moderate-to-severe (PTA-4 = 55–69 dB)
Severe (PTA-4 = 70–89 dB)		 7 (19.4%)
12 (33.3%)
11 (30.6%)
2 (5.6%)
PTA-4 unaided M
range 		51.67
30–91
Age identified with hearing loss M
range in months 		7.0 months
birth—39
Age at hearing aid use M
range in months 		10.4 months
1–39
Age of enrollment in early intervention M
range in months 		10.4 months
1–39
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PTA-4 = Pure tone average threshold (hearing level from 500 Hz to 4,000 Hz for both ears).

* p < .05

* * p < .01

* * * p < .001

Children with HL

All children with HL had permanent bilateral sensorineural HL and all utilized hearing aids. As displayed in Table 2, hearing levels were in the moderate and moderate-to-severe range for more than half of the children (63.9%). Approximately 86.1% of the children were identified through newborn hearing screening procedures. The average age of identification and age at initial amplification with hearing aids were 7.0 and 10.4 months, respectively. Twenty-nine children with HL (80.6%) had an Individual Education Plan (IEP) and received speech-language services. All children used spoken language as their mode of communication.

Procedures and Measures

Recruitment and testing

As a general protocol for the larger investigation, parents and their children with HL were recruited from the clinical population (e.g., computer-generated lists, clinician referrals) at each research site. Parents and children with TH were a convenient sample that included (1) siblings of children with HL who participated in other studies at the two research sites; (2) children of professionals working at the clinic settings; or (3) children recruited from outside the centers. Parents completed a demographic questionnaire that gathered family (e.g., parent age, marital status, income) and child (e.g., age, gender, participation in preschool) information, as well as perceptions of SBR experiences prior to their research appointment. Parent–child SBR interactions were video recorded, and child hearing and language assessments were conducted at each research site by licensed speech-language pathologists and audiologists with extensive experience evaluating children with HL.

Demographic Information and Parental Report of HLEs

In addition to providing general parent and child demographic information, parents of children with HL completed questions regarding their child’s HL, newborn hearing screening information, age at identification of HL, initial age of amplification, age of enrollment in an early intervention program, and speech-language services. Auditory information such as pure tone average (PTA-4) and degree of HL was obtained from an audiologic evaluation conducted by a licensed pediatric audiologist as part of the global assessment battery. Using a 5-point Likert scale, parents of children with and without HL completed three questions regarding their perceptions of their HLE. Questions included: (1) To what extent does your child seem to enjoy looking at storybooks with you?; (2) How many minutes per day do you and your child read books together?; and (3) To what extent is it easy to read storybooks with your child? The mean score for each question was used in the data analyses.

Shared Book Reading Interactions

Parents and their children were videotaped during shared book reading interactions. The interactions were conducted in a comfortable, quiet room at each research site. A remote-controlled camera (Sony EVID70p) was mounted on a shelf in the room approximately 2 ½ feet from the floor. Parents wore a wireless microphone (G2 Sennheiser 100 series) and were seated near their child on the carpeted floor. A condenser microphone (Beyerdynamic 5-inch gooseneck) was centrally mounted on the ceiling of the room to ensure optimal acoustic recordings. The output of each camera was captured (Osprey 450e capture board), mixed (video and audio), and digitized (Telestream Episode software). The digitized video/audio files were transferred via a secure cloud-based website from the research site to the first author. There were no significant differences between groups for the length of videotaped interaction (HL mean = 9.16 min; TH mean = 9.38 min).

Parents were seated on a carpeted floor with their children and instructed to interact with the storybooks as they would typically do at home. Two wordless picture books were used during the SBR sessions: Unbrella (Franson, 2007) and A Boy, a Dog, and a Frog (Mayer, 2003). Parents could choose either book to begin with and then continue with the second book when they were finished with the first book. The wordless picture books were selected purposefully to encourage parents’ own natural linguistic input and children’s narrative language. Recent findings (Campbell et al., in review) suggest that wordless picture books rather than books with words encourage more spontaneous language by parents of children with HL. Similar books have been used in prior SBR interaction studies with TH children (Weizman & Snow, 2001) and children with HL (DesJardin et al., 2014, 2017; DesJardin & Eisenberg, 2007).

Preschool Language Scale-Fourth Edition (PLS-4)

Children were administered the PLS-4 (Zimmerman, Steiner, & Pond, 2002) on the same day as the SBR recordings. The PLS-4 is a clinician-administered standardized test that assesses language skills in children from birth to 6 years, 11 months. PLS-4 is composed of two subscales, Auditory Comprehension (AC) and Expressive Communication (EC), that use pictures and toys as stimuli to target communication skills in the areas such as attention, play, gesture, vocal development, vocabulary, and social communication. PLS-4 is commonly used with TH children and children with HL (Ching et al., 2010; DesJardin et al., 2017; Fitzpatrick, Durieux-Smith, Eriks-Brophy, Olds, & Gaines, 2007; Geers, Moog, Biedenstein, Brenner, & Hayes, 2009). Children’s total language standard scores (SSs) comprised the outcome variable.

Coding

The Responsive Adult-Child Engagement During SBR (RACED-SBR) scale (DesJardin, 2011) was designed to measure parent and child SBR behaviors shown to predict language development in populations of young children with TH (Barnes & Puccioni, 2017; Edwards et al., 2008; see Appendix A for parent and child behaviors). The RACED-SBR scale consists of the following five sections: (1) adult and child engagement (six adult behaviors and five child behaviors); (2) adult literacy strategies (four adult behaviors); (3) adult teaching techniques (five adult behaviors); (4) adult and child interactive reading (five adult behaviors and seven child behaviors); and (5) child guided reading (five child behaviors). A total mean score for each parent and child subscale was calculated and used in the data analyses. The first author and a research assistant rated each adult and child SBR behavior individually on a 3-point Likert-type scale ranging from 0 (no evidence) to 3 (most of the time). Cronbach’s coefficients for each subscale suggested high internal consistency (range = .88 to .92 for adult behaviors and .90 to .95 for child behaviors) between the first author and research assistant. To establish inter-rater reliability for SBR behaviors, a second research assistant coded 20% of the randomly selected videotaped data. This included 10 parent–child TH dyads and eight parent–child HL dyads. Adult SBR behaviors ranged from 85% to 93% agreement, whereas child behaviors ranged from 85% to 95% agreement.

Results

Preliminary Analyses

Parents and their children (HL and TH) were similar in terms of demographic variables. Although the parents and children were predominantly White (HL = 80.6% and TH = 85.4%), the sample was diverse relative to ethnicity, with 25.0% of parents in the HL group and 12.2% of parents in the TH group identified as Hispanic. For parents and children with HL and with TH, ethnicity was positively related to children’s total language scores, HL parent r = .60 p = .011 and child r = .43 p = .051; TH parent r = .40 p = .015 and child r = .32; p = .052. For parents of children with TH only, parent education level, r = .47, p = .014 and total household income, r = .39; p = .012 were positively related to children’s total language scores.

Significant group differences emerged in terms of child total language SS as measured by the PLS-4, F = 6.87; p = .010. Children of non-Hispanic parents in both groups were more likely than children of Hispanic parents to demonstrate better English language skills. Thus, child total language SS was chosen as the control variable in all subsequent analyses.

Research Question 1: Between-Group Comparisons

Our first research question addressed group differences between parents of preschool-age children with and without HL in terms of parents’ reported home literacy experiences (e.g., frequency of book reading) and observed parent and child SBR behaviors. A two-group (HL versus TH) multivariate analysis of covariance, which employed children’s PLS-4 Total SS as a covariate, was performed using the three items from the home literacy questionnaire (frequency of book reading, ease of reading to child, child enjoyment of book reading), four observed SBR parent behaviors (engagement, teaching techniques, literacy strategies, and interactive reading), and three child behavior subscales (engagement, interactive reading, and guided reading). Chi-square analysis was used to compare the proportion of children in each group to confirm the significance between groups. Consistent with conventional practice, we utilized a type I error rate of α = .05 (two-tailed) for group mean comparisons. To reduce the likelihood of producing false-positive results (type 1 errors) from multiple comparisons, the Benjamini–Hochberg (B–H) procedure (Benjamini & Hochberg, 1995) was applied using a false discovery rate of 5%. All statistical analyses were carried out using SPSS version 28 (IBM SPSS Statistics for Windows 2021) (IBM Corp 2021).

Parent report of HLE

As shown in Table 3, no significant differences emerged between the HL and TH groups with respect to ease of reading to child or child enjoyment during SBR. For parents of children with HL, 69.5% reported that it was “easy” or “very easy” reading to their preschool-age children compared to 73.4% for TH group. Further, chi-square analyses indicated no significant differences between groups for ease of reading to their child, X2(2, N = 85) = 6.63, p = .157. In terms of child enjoyment, 69.5% of parents of children with HL reported that their child enjoyed SBR “quite a bit” to “extremely so,” whereas 87.8% was reported for the TH group. Chi-Square analysis indicated significant differences between groups for child enjoyment, X2(2, N = 85) = 15.34, p = .004 with children with TH enjoying SBR more than children with HL. Significant differences also emerged between groups in terms of time reading to their children per day (1 = “no time” to 5 = “>30 minutes per day”), F = 14.27; p = .001 ŋ2 = .148. As cited by Dunst and Hamby (2012), .01 is considered a small effect size, .06 is considered a medium effect size, and .14 is considered a large effect size. Therefore, a large effect size was evident for the frequency of book reading per day. Parents of children with HL reported more daily SBR than parents of children with TH. In fact, 52.8% of parents of children with HL (N = 19) reported that they read more than 20 min per day, whereas 24.5% of parents of children with TH (N = 12) reported the same. These group differences remained significant after applying the B-H procedure (Benjamini & Hochberg, 1995).

Table 3.

Summary statistics and between-group comparisons for parents’ perceptions of home literacy experiences, and parent and child SBR subscales

Hearing loss n = 36 M (SD) Typical hearing n = 49 M (SD) F-scores p-values Eta-squared
Home literacy experiences  
Frequency of SBR
Ease of reading
Child enjoyment
3.57 (.88)
4.03 (1.02)
3.94 (1.33)
3.15 (.85)
4.02 (.73)
4.29 (1.04)
14.27
.531
4.86
<.001  
.468
.488
.148
.006
.006
Parent Shared Book Reading Behaviors  
Engagement
Literacy strategies
Teaching techniques
Interactive reading
12.92 (3.24)
6.94 (1.55)
5.92 (2.68)
11.19 (2.82)
13.446 (2.54)
7.69 (1.32)
7.63 (2.33)
12.52 (2.08)
2.69
9.07
8.18
4.46
.105
.003
.005
.072
.034
.101
.092
.063
Child Shared Book Reading Behaviors  
Engagement
Interactive reading
Guided reading
10.61 (3.03)
6.22 (2.91)
8.67 (2.75)
12.21 (2.15)
9.40 (3.07)
9.27 (1.39)
1.58
7.31
.018
.212
.008
.894
.019
.083
.000
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*Note: p-values marked in bold remained significant after the B-H procedure was applied to control for Type I error in multiple testing.

* p < .05

Parent SBR behaviors

A two-group (HL versus TH) multivariate analysis of covariance was performed with children’s PLS-4 total SS as the covariate and using parent SBR subscales as the dependent variables. As shown in Table 3, no statistically significant differences emerged between groups in terms of parent engagement and interactive reading strategies. However, significant differences were evident for parent behaviors in terms of literacy strategies, F = 9.07; p = .003 ŋ2 = .10 and teaching techniques, F = 8.18, p = .005 ŋ2 = .09. Parents of children with HL scored lower on both subscales compared to parents of children with TH. Therefore, a medium effect size was evident for both parent literacy strategies and teaching techniques. Further univariate analysis of covariance, employing children’s PLS-4 total SS as a covariate was performed to explore the differences between specific parent behaviors for each subscale. For parents’ literacy strategies, a significant difference emerged for one parent behavior: points to and labels pictures in the book (B1), F = 5.15, p < .026 ŋ2 = .06. For parent teaching techniques, significant differences were evident for three parent behaviors: relates content to prior experiences (C1), F = 7.58, p = .007 ŋ2 = .09, defines new vocabulary (C3), F = 5.10, p = .027 ŋ2 = .06 and solicits predictions (C4), F = 4.04, p = .048 ŋ2 = .05. These group differences remained significant after applying the B–H procedure (Benjamini & Hochberg, 1995). Parents in the HL group scored lower on both literacy strategies and teaching techniques during SBR compared to parents of preschool-age children with TH.

Child SBR behaviors

A two-group (HL versus TH) multivariate analysis of covariance was performed with the children’s PLS-4 total SS as the covariate and the child SBR subscales as the dependent variables. No statistically significant differences emerged for child engagement or guided reading behaviors. However, significant differences were evident for interactive reading behaviors, F = 7.31, p = .008 ŋ2 = .08 with children with HL scoring lower on this subscale compared to children with TH (see Table 3). A medium effect size was evident for interactive reading. Further univariate analysis of covariance, employing children’s PLS-4 total SS as a covariate, was performed to explore the differences between specific interactive reading behaviors. Significant differences were evident for four child behaviors: responds to questions about the book (B1), F = 16.58, p = .001 ŋ2 = .18, which was a large effect size; offers spontaneous ideas about the book or related topic (B3), F = 6.78, p = .011 ŋ2 = .08; recalls information from earlier in the book (B6), F = 6.35, p = .014 ŋ2 = .08; and makes predictions about what will happen next in the book (B7), F = 7.53, p < .008 ŋ2 = .09. A medium effect size was evident for the last three child behaviors: offers spontaneous ideas about the book, recalls information from earlier in the book, and makes predictions. These group differences remained significant after applying the B–H procedure (Benjamini & Hochberg, 1995).

To summarize, after controlling for children’s total language SSs, parents of children with HL demonstrated fewer literacy strategies and teaching techniques, while children with HL demonstrated less use of interactive reading behaviors during SBR compared to parents and their preschool-age children with TH.

Research Question 2: Associations Between SBR Variables and Total Language Scores for Children With HL

To answer our second research question, a series of Pearson product-correlations were conducted between the (1) three parent questions about home literacy experiences, (2) observed parent and child SBR behavior subscales, and (3) children’s total language SSs for parents and their children with HL. Significant positive relationships were evident between two of the three home literacy items (e.g., frequency per day and child enjoyment) and children’s total language SSs, ranging from r = .44; p = .011 to r = .63; p = .014. The strongest correlation was between the frequency of book reading and total language, r = .63; p = .011. For parent SBR behaviors, parent literacy strategies, r = .40; p < .05, teaching techniques, r = .54; p = .010, and interactive reading, r = .43; p = .053, were positively related to children’s total language SSs. Furthermore, child SBR behavior subscales, engagement, r = .38; p = .051, guided reading, r = .37; p = .052, and interactive reading, r = .61; p = .013, were all positively associated with child language scores. After applying the B–H procedure (Benjamini & Hochberg, 1995) using a false discovery rate of 5%, these specific relationships remained significant.

Exploring relationships between home literacy experience questions and parent SBR behavior subscales also revealed significant positive relationships, all ranging from r = .43; p = .053–.63; p = .013. The strongest relationships were evident between parent teaching techniques and parent interactive reading, and frequency of book reading, r = .63; p = .014 and r = .58; p = .012. After applying the B–H procedure (Benjamini & Hochberg, 1995), relationships between the three home literacy questions and parent SBR behavior subscales remained significant. Similar results occurred for the relationships between home literacy questions and child SBR behavior subscales revealing significant positive relationships, all ranging from r = .44; p = .011–.60; p = .014.

Research Question 3: Predictors for Child Language Skills for Children With HL

Significant reported home literacy experience and parent–child SBR behaviors were associated with child language total scores in the previous analysis. Stepwise multiple regression analysis was utilized to determine each variable’s contribution to child total language score. Independent variables demonstrating the strongest positive relationship with children’s total language score in the previous correlation analyses were included in the stepwise multiple regression analysis (frequency of book reading, parent teaching techniques, and child interactive reading behaviors) to explore which predictor variables of the home literacy environment were associated with children’s total language SS. As shown in Table 4, the frequency of book reading accounted for 39.9% of the variance, with children’s interactive reading behaviors accounting for an additional 11.0% of the variance in children’s total language scores.

Table 4.

Summary of regression models of home literacy experiences and shared book reading behaviors for children’s total language outcome

Step-wise regression models R R2 Change in R2 Significance of F change
Home literacy experiences  
Frequency of shared reading
Parent teaching techniques
Child interactive reading
.632
.654
.713
.399
.427
.509
.399
.029
.110
<.001
.239
.017
Predictors for final model  
Frequency of shared reading
Child interactive reading		 B  
.404
.402		 p  
.016
.017
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Discussion

A strong foundation in language skills is necessary to support school readiness and pre-literacy skills in young children with HL who utilize hearing aids prior to entering kindergarten (DesJardin et al., 2011; DesJardin et al., 2017; DesJardin & Ambrose, 2010; Harrington et al., 2010). However, much variability in language skills exist in preschool populations of children with hearing aids (Koehlinger et al., 2013; Tomblin et al., 2015). Children entering kindergarten with low language skills can be at risk for delays in kindergarten early literacy skills (Thompson, 2017) and later academic skills (Jin et al., 2020). Furthermore, children with limited opportunities to be immersed in language-rich interactions during the preschool years often do not develop the language skills expected for kindergarten curriculum in current public schools (Barnes & Puccioni, 2017). To date, this is the first study to investigate parents’ report of their HLEs and observed parent and child SBR behaviors in parents and their preschool-age children with HL who utilize hearing aids. A control group comprised of TH children and their parents helped clarify the impact of HL on home literacy experiences, including parent and child behaviors during interactive SBR.

The first research question examined parents’ reports of their HLEs (frequency of book reading, ease of reading, and child enjoyment of SBR) between groups of parents and their children with and without HL. Unlike prior studies of parents with younger populations of HL (DesJardin et al., 2017) and preschoolers with HL (Reynolds & Werfel, 2020), parents of children with and without HL in this study differed significantly in terms of frequency of book reading at home. Parents of preschoolers with HL reported reading more to their children than parents of children with TH. In fact, 52.8% of parents of children with HL reported reading more than 20 min per day compared to only 24.5% for parents of children with TH. Most of the children with HL in this study (80.6%) had an IEP and were attending a program for children with HL. This group of children with HL also had more than three years of early intervention experience. It could be the case that parents of children with HL were receiving more consistent information about the importance for daily SBR compared parents of children with TH. Similar to prior research with preschool-age children with TH (Farrant & Zubrick, 2013; Grollig et al., 2019) and with HL (Campbell et al., in review; DesJardin et al., 2017), the frequency of book reading was also significantly related to children’s total language scores for both groups in this study. It is essential that professionals continue to encourage parents to read often to their preschool children with HL.

Overall, there were no significant differences between groups in terms of ease of reading by parents to their child and child enjoyment of SBR. Although earlier research indicated greater difficulty in parents’ perceived reading to their toddlers with HL (DesJardin et al., 2017; Swanwick & Watson, 2007; Zaidman-Zait & Dromi, 2007), parents of preschool-age children in this study did not report that reading to their children was difficult. It is possible that as children mature and have more SBR experiences, parents perceive that their children engage in storybooks longer and are more attentive. Furthermore, significant group differences emerged for child enjoyment, with parents of children with HL reporting less child enjoyment than parents of children with TH. Results from this study also indicate that the children with HL demonstrated fewer responses to questions, spontaneous ideas, and predictions about the book compared to their TH peers. It is possible that parents perceive their children as displaying less enjoyment during SBR because the children demonstrate fewer responses to questions and offer less spontaneous ideas about the books. Similar to previous research findings regarding the relationship between parents’ ease of reading to their child and language skills in young children with TH (Blewitt & Langan, 2016; Karrass & Braungart-Rieker, 2007; Trivette et al., 2010) and children with HL (DesJardin et al., 2017), ease of reading and child enjoyment were both positively related to children’s language skills for the group of children with HL. Because this was a correlational study, we were not able to examine whether children’s language skills predict child enjoyment during SBR activities. Nevertheless, what is clear from the results of the current study is the importance of supporting children’s linguistic attempts during SBR.

Although prior research on younger children with HL suggests that parents of children with HL demonstrate fewer interactive behaviors than parents of children with TH (DesJardin et al., 2017), the results of this study did not find that to be true for parents of preschool-age children with HL. After controlling for children’s total language skills, parents of children with HL and TH equated on parent observed behaviors related to parent engagement and interactive reading behaviors. Specifically, both groups of parents (TH and HL) were equally observed sustaining their child’s attention (e.g., eye contact, facial expressions), providing positive feedback, maintaining proximity to their children, responding to their children’s vocalizations, and allowing time for children to process new information. These same strategies were found to increase substantially over time given a parent training program specifically to enhance shared book reading strategies in parents in their young children who are deaf or hard of hearing (Dirks & Wauters, 2018).

In contrast, significant differences emerged between groups of parents in terms of parent SBR observed behaviors related to literacy strategies and teaching techniques. Unlike prior research reporting that parents of toddlers with HL provided more literacy strategies than a TH control group (DesJardin et al., 2014), parents of preschoolers with HL provided fewer literacy strategies (e.g., points to and labels pictures in the book) and teaching techniques (e.g., relates content to prior experiences, defines new vocabulary, solicits predictions) than parents of preschool-age children with TH. These same literacy strategies and teaching techniques may be more difficult for parents of young children with HL (Swanwick & Watson, 2007) and to sustain over time (Dirks & Wauters, 2018). Teaching techniques that solicit predictions (i.e., posing why and how questions) during SBR encourage longer child utterances in preschool-age children with TH (Deshmukh et al., 2019; Roberts et al., 2019) and both literacy strategies and teaching techniques were positively associated to total language skills for this population of preschool children with HL.

In terms of child behaviors during SBR, after controlling for children’s total language scores, no significant differences emerged for child engagement and guided reading. Similar to prior research (Swanwick & Watson, 2007), both groups of children in this study demonstrated equal frequency of behaviors such as seeking and maintaining proximity to parent and sustaining interest in the storybooks, as well as pointing to pictures and showing overall enjoyment. However, similar to younger populations of children with HL (DesJardin et al., 2017; Zaidman-Zait & Dromi, 2007), significant differences emerged between groups of children with and without HL in terms of interactive reading behaviors. Specifically, children with HL in this study demonstrated fewer responses to questions about the book, spontaneous ideas, and predictions compared to preschool-age children with TH. These results are concerning as children’s active participation and observed interactive reading behaviors positively influence expressive language development for young children with TH (Blewitt & Langan, 2016; Crain-Thoreson & Dale, 1992; Sénéchal, 1997; Trivette et al., 2010) and hold true for this population of preschool-age children with HL who utilize hearing aids.

The third research question further explored parent HLE and observed behaviors and child SBR behaviors that related to total language skills in children with HL. Regression analysis provided a more in-depth understanding of the role that children play in their language development during SBR interactions. Similar to prior research on children with TH (Blewitt & Langan, 2016; Mol et al., 2008; Sénéchal, 1997; Trivette et al., 2010) and children with HL (DesJardin et al., 2017), findings from this study revealed that frequency of book reading accounted for 39.9% of the variance in children’s total language skills, whereas children’s interactive reading behaviors accounted for another 11.0% of the variance in children’s total language scores. Although parents’ use of specific literacy strategies and teaching techniques may support children’s language skills, results from the current study further indicated that children’s interactive behaviors played a significant role during SBR parent–child interactions. Specifically, child behaviors that include asking questions about the story, referring to characters or settings, and making predictions about what will happen next in the story all contributed significantly to children’s total language skills. To our knowledge, this is the first study that showed that over and beyond observed parent strategies and parental report of child engagement, observed child interactive behaviors are essential for language learning during shared book reading interactions. Most concerning, even after controlling for language skills, children with HL in this study scored lower in those same observed interactive reading behaviors (e.g., asking questions, commenting on the pictures, spontaneous ideas) compared to their peers with TH. In other words, even after equating children’s language abilities, children with HL were observed less in terms of initiating language during SBR. These same children with lower interactive behaviors could be at further risk for language delays as they enter kindergarten.

Limitations and Future Directions

This study investigated HLE factors, and the relationships between child and parent SBR behaviors and children’s language skills. Although it provides us with cross-sectional findings and predictive relationships, it does not take advantage of the longitudinal design used in the original study (Stika et al., 2015). Thus, it could be the case that other child factors (e.g., quality of preschool program, teacher talk in preschool, number of days attending preschool) may have a stronger influence on language skills for this population of children with mild-to-severe HL. Future analyses of various factors at later time points (e.g., kindergarten, early school-age) will provide a much broader understanding of the precise mechanisms that guide school readiness efforts. Additionally, although this is a fairly large sample of diverse parents and their children with HL and children with TH, the present sample was primarily White and spoke English. Future studies that investigate families of young children with HL who are more culturally and linguistically diverse will provide a more generalized outcome (McNaughton, 2006). Nevertheless, findings from this study highlight the importance of both the frequency of book reading and parent and child behaviors during SBR that may support language skills in preschool-age children with HL prior to entering kindergarten programs.

Implications for Practitioners Working With Families of Children with HL

With significant improvement in hearing technology and early intervention efforts, a greater number of preschool-age children with HL will enter inclusive kindergarten classrooms. Preschool-age children who enter kindergarten with strong language skills have a better opportunity to access early childhood curriculum (Thompson, 2017). Early child factors (e.g., age of HL identification and HA fitting, amount of hearing aid use) have shown to positively relate to better language and school readiness skills in children with HL (Campbell et al., in review; DesJardin et al., 2011; DesJardin et al., 2014; Harrington et al., 2010; Tomblin, Oleson, Ambrose, Walker, & Moeller, 2014; Meinzen-Derr et al., 2020). Still, high variability exists in language skills for this population (Fitzpatrick et al., 2007; Tomblin et al., 2015). Applying the findings from this study can provide professionals with guidance as they support parents who have preschool-age children with HL who utilize hearing aids prior to entering kindergarten.

The National Association of Education of Young Children (NAEYC, 2012) highlights home literacy experiences, specifically SBR, to support children’s language development. Parents play a critical role during SBR as they learn how to interact with their children during SBR to support their children’s language learning (DesJardin, 2009; DesJardin & Ambrose, 2010; Dirks & Wauters, 2018; Farquharson & Babeu, 2020; Fung, Chow, & McBride-Chang, 2005; Trussell & Easterbrooks, 2014). Findings from this study support two early intervention efforts for early childhood programs during the preschool years for parents and their preschool-age children with HL. First, the sheer amount of reading books to children appears to be critical. Recent evidence suggests that parents reading more than 30 min per day relate to early language and literacy skills in children with cochlear implants (Campbell et al., in review) and children with hearing aids (DesJardin et al., 2014). Findings from this study also support the notion that more interactive reading per day relates to better language outcomes for preschool-age children who utilize hearing aids. Preschool teachers and other professionals that work with families of children with HL should encourage parents to read to their children daily and supply families with appropriate storybooks, if needed.

Parent training programs are a promising way to explicitly demonstrate and build parents’ sense of confidence in specific strategies while reading storybooks to preschool children with HL (Dirks & Wauters, 2018; Farquharson & Babeu, 2020; Nelson, Stoddard, Fryer, & Munoz, 2019). Specific strategies modeled and intentionally taught to parents during SBR sessions are necessary (DesJardin & Ambrose, 2009; DesJardin et al., 2009; Dirks & Wauters, 2018). Indeed, parental interactive reading behaviors require adults to “read with their child rather than reading to their child” (Dirks & Wauters, 2015, p. 420). For instance, parental use of teaching techniques such as relating the story to the child’s prior experiences, defining new vocabulary, and soliciting predictions are all important strategies that cultivate an interest in reading and support new vocabulary and emerging literacy (e.g., comprehension) skills for young children with HL (DesJardin et al., 2009; Fung et al., 2005). Eliciting language interaction by asking open-ended why and how questions about the storybook and actively responding to child initiatives are also important to the SBR experience (DesJardin et al., 2014). Furthermore, specific key adult strategies such as prediction questions and recasts have been reported to support children’s language development and may likely elicit more verbal responses from children during SBR (Cleave et al., 2015; Deshmukh et al., 2019).

However, parents do not apply all strategies to the same extent, and the use of strategies can vary considerably (DesJardin et al., 2017; Dirks & Wauters, 2018). For example, Dirks and Wauters (2018) findings suggest that parents’ use of interactive reading (e.g., following child’s lead) and engagement strategies (e.g., positive feedback, maintaining proximity to child) increased over time, while teacher techniques (e.g., defining vocabulary) and literacy strategies (e.g., asking questions about the book) were demonstrated less often (Dirks & Wauters, 2018). Thus, parents may need additional and frequent practice and support in using these specific strategies over time. Using video-feedback techniques could provide an opportunity for professionals to highlight parents’ strengths and identify strategies to better support child engagement and linguistic responses during SBR (Lam-Cassettari, Wadnerkar-Kamble, & James, 2015; Wadnerkar-Kamble, Lam-Cassettari, & James, 2020). Professionals working with families and their young children with HL can play an important role by modeling and monitoring strategies during preschool home visits or family workshops and training.

This is the first study to highlight the critical role that children with HL can play in their language learning. Preschool children with HL will need more opportunities to intentionally engage with storybooks. Professionals working with families will need to not only guide parents but also demonstrate ways for parents to elicit their children’s linguistic attempts through explicit and intentional SBR opportunities. Utilizing an observational tool such as the Adult-Child Interactive Reading Inventory (ACIRI, DeBruin-Parecki, 2007) can quantify children’s attempts as children comment on pictures, ask questions, and make predictions during SBR. The ACIRI manual also provides professionals with at-home activities and storybook suggestions to promote parent and child behaviors during SBR. The ACIRI manual includes the use of wordless picture books. Children are more engaged, and parents provide more questions while sharing a wordless picture book rather than books with words (Arizpe, 2013; Campbell et al., in review; Chaparro-Moreno, Reali, & Maldonado-Carreño, 2017). Wordless picture books, through the lack of a pre-prescribed reading script, encourage parents and children to engage more actively in the shared book reading interaction. Results from the current study suggest that parents of preschool-aged children with HL may need further guidance on how to utilize strategies to engage children using wordless picture books. Furthermore, professionals who work with families of children with HL will need to identify those children with lower language abilities and provide parents with additional coaching to promote their children’s language skills (Wauters, DesJardin, & Dirks, 2021). Preschool-age children with HL who utilize hearing aids will benefit from early childhood programs that encourage frequent shared book reading and provide intentional ways to guide parents and their children during SBR prior to entering kindergarten.

Data Availability

Data is available upon request.

Acknowledgements

We want to thank research assistant, Ms. Gabriella Nasta from Moravian University for coding the SBR interactions. A very special thank you extends to all the parents and their preschool-age children who participated in this study.

Contributor Information

Jean L DesJardin, Education Department, Moravian University, Bethlehem, PA, USA.

Carren J Stika, School of Speech, Language, and Hearing Sciences Audiology Department, San Diego State University, San Diego, CA, USA.

Laurie S Eisenberg, Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

Karen C Johnson, Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

Dianne Hammes Ganguly, Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

Shirley C Henning, Caruso Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Funding

National Institute on Deafness and Other Communication Disorders (NIDCD) of the National Institutes of Health (grant number R01 DC009561, R01 DC 009561-01S1).

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