Responsive parenting intervention after identification of hearing loss by Universal Newborn Hearing Screening: The concept of the Muenster Parental Programme

International Journal of Pediatric Otorhinolaryngology 77 (2013) 2030–2039

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Responsive parenting intervention after identification of hearing loss by Universal Newborn Hearing Screening: The concept of the Muenster Parental Programme Karen Reichmuth *, Andrea Joe Embacher, Peter Matulat, Antoinette am Zehnhoff-Dinnesen, Reinhild Glanemann Clinic for Phoniatrics and Pedaudiology, University Hospital Muenster, Germany

A R T I C L E I N F O

A B S T R A C T

Article history: Received 20 June 2013 Received in revised form 1 October 2013 Accepted 3 October 2013 Available online 12 October 2013

Background: Parents of newborns with hearing loss (HL) identified by Universal Newborn Hearing Screening (UNHS) programmes wish for educational support soon after confirmation and for contact with other affected families. Besides pedaudiological care, a high level of family involvement and an early start of educational intervention are the best predictors for successful oral language development in children with HL. The implementation of UNHS has made it necessary to adapt existing intervention concepts for families of children with HL to the needs of preverbal infants. In particular, responsiveness has proven to be a crucial skill of intuitive parental behaviour in early communication between parents and their child. Since infants with HL are being fitted earlier with hearing devices, their chances of learning oral language naturally in daily communication with family members have noticeably improved. Objectives: The Muenster Parental Programme (MPP) aims at empowering parents in communicating with their preverbal child with HL and in (re-)building confidence in their own parental resources. Additionally, it supplies specific information about auditory and language development and enables exchange with other affected parents shortly after the diagnosis. Concept: The MPP is a responsive parenting intervention specific to the needs of parents of infants with HL identified by UNHS or through other indices and testing within the first 18 months of life. It is based on the communication-oriented Natural Auditory Oral Approach and trains parental responsiveness to preverbal (3–18 months) infants with HL. The MPP has been developed for groups of 4–6 families and comprises six group sessions (without infants), two single training sessions with video feedback, and two individual counselling sessions. At the age of 24–30 months, an individual refresher training session is offered to the parents for adapting their responsiveness to the current verbal level of the child via dialogic book reading. The programme also benefits parents of paediatric cochlear implant (CI) candidates preimplantation and postimplantation. Conclusions: The MPP is evidence-based (see Glanemann et al., this volume) and meets the current need for effective family-centred educational intervention after UNHS. ß 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords: Early intervention Hearing loss Infant Parents Preverbal communication Responsiveness

1. Introduction Abbreviations: CI, cochlear implant; CHIP, Colorado Home Intervention Program; FLIP, Linz Family Centred Intervention Program; HL, hearing loss; HPLI, Heidelberg Parent-based Language Intervention; ITTTT, It Takes Two To Talk; MPP, Muenster Parental Programme; NH, normal hearing; PALS, Playing and Learning Program; RE/ PMT, Responsiveness Education/Prelinguistic Milieu Teaching; RFI, Relationship Focused Intervention; STEEP, Steps Towards Effective Enjoyable Parenting; UNHS, Universal Newborn Hearing Screening. * Corresponding author at: Department of Phoniatrics and Pedaudiology, University Hospital Muenster, Kardinal-von-Galen Ring 10, 48129 Muenster, Germany. Tel.: +49 251 8356905. E-mail address: [email protected] (K. Reichmuth). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.10.002

The identification of HL by Universal Newborn Hearing Screening (UNHS) programmes aims at enhancing the child’s communicative, academic and social development. These programmes have noticeably improved the likelihood for these children to develop an oral language competence that is comparable to their hearing peers [1–3]. However, early identification is only beneficial when quality services for the child and its family are implemented to take advantage of this

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early detection [3–5]. Moreover, parents may become distressed when the confirmation of HL is not followed by immediate support and can consequently fear losing the advantage of early identification [4]. Especially for parents with no family history of HL, the diagnosis comes unexpectedly and at a time when they are fully engaged in bonding with their newborn. They are easily overwhelmed by grief, with a need for making decisions concerning communication mode or cochlear implantation, and uncertainty and helplessness in the face of an unexpected situation for which they could not prepare [6]. Consequently, parents often lack confidence in child rearing and may express irritations in their behaviour and communication towards their child. This in turn can influence their intuitive and childoriented parental behavioural repertoire, also called intuitive parenting [7,8]. This mostly unconscious set of behaviours is easily irritated when parents are confronted with unexpected conditions like illness or special needs of the child [9]. Beyond that, the infants with HL may show varied forms of communicative signals due to differences in auditory access [6]. In this situation, support for the parents is needed to help them discover and value the individual communicative signals of their child. In particular, the nature of the interaction between the child with HL and his/her parents and the quality of the language environment the child experiences have been emphasised as crucial influential factors his/her language development [10– 12]. Besides early identification and near-term fitting of adequate hearing devices, it is the early start of educational intervention in combination with a high level of parental participation that best predicts successful language development [13–15]. As a consequence, health care professionals are confronted with much younger children and their families than in previous decades. Therefore, existing early educational intervention concepts have to be adapted to the infant’s preverbal period and to meet the special needs of parents [16,17]. To face this challenge, after the nation-wide implementation of UNHS programmes in Germany in 2009, we have aimed to develop a programme that supports families in the initial period following confirmation of HL. This parental programme needed to be targeted at early onset ages, placing emphasis on high family involvement, with the ability to be specific to the needs of parents and their infants with HL. The result of these considerations is the Muenster Parental Programme (MPP) which is utilised as a module of early intervention in a multiprofessional team supporting families immediately after the confirmation of the HL. The overall objective of the MPP is to empower parents by (re)building confidence in their own parental skills and to give them the opportunity to share their experiences with other affected families. Resourcing parents with communication and behavioural skills and enabling exchange with other concerned parents has been shown to reduce parental stress [10]. Parents themselves value the contact with other affected parents and consider this interaction to be very supportive [16,18]. Clark [19] stresses that drawing on the patterns of early language learning in children with NH as a model for those with a HL is important. Consequently, a programme that aims at improving parents’ natural communication skills towards their preverbal hearing-impaired infant should consider not only knowledge about normal preverbal development but also the supporting role parents take on intuitively in the process of language development. Moreover the characteristics and further functions of intuitive parenting as parental support for preverbal development should be looked at in more detail.

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1.1. Preverbal communication: dialogue from the very first moment The preverbal stage encompasses about the first 18 months of an infant’s life characterised by two major transitions (1) the transition from preintentional to intentional communication and (2) the transition from presymbolic to symbolic communication [20,21]. Parents support their infant on his/her way to intentional and symbolic communication as a foundation for verbal communication. From birth on, the dialogic character of communicative exchange between infant and parent is an outstanding attribute of their preverbal communication [8,22]. The infant needs help to categorise environmental stimuli and his/her own unconscious behaviour. Parents intuitively answer promptly to the infants’ signals, such as vocalisations or yawning as well as non-verbal behaviours. They mirror the infant’s vocalisation or mime and interpret the affect lying behind it. These parental responses in daily activities help the infant to learn about his/her own affects and self-efficacy, as a foundation for later intentional communication. Preverbal dialogues present the ideal condition and frame for such learning [8,22,23]. In these dialogues, parents intuitively adjust their interactive behaviour to the infant’s limited repertoire by parsing, exaggerating and repeating while concentrating on the infant’s focus of attention. So this feedback structures and clarifies perceived stimuli for the infant, as well as the interaction [23,24]. The prosodically modified parental speech style of intuitive parenting serves different functions throughout the first year including (a) regulation of attention and affects, (b) communication of intentions and emotions, (c) perception of prosodic features serving different meanings, and finally (d) stressing first words [23,24]. Both infants and parents are biologically predisposed for these early dialogues, which help the child to learn about its social and physical environment and to become an effective communicative partner [8]. In this way, parents intuitively support the child’s development by emphasising its newly emergent skills [6]. The older the child becomes the more that parents expand their responses [8]. A main resource of this intuitive and highly didactic parental behaviour is responsiveness. In the literature the concept of ‘parental responsiveness’ overlaps with the concept of ‘maternal sensitivity’ (see [25–27] for discussion). Both concepts are closely related [27] without a satisfactory differentiation between them until now. Consequently, the following definition of ‘parental responsiveness’ that underlies the MPP is provided for clarification. 1.2. Parental responsiveness To be ‘responsive’ means to allow the child to be the leading person in communication, to react immediately to its communicative attempts by imitating the child’s signal and to respond to this in an expanding way [28,29]. Parental responsiveness provides contingent responses in shared activities that build on joint attention [26,29]. Responses not only refer to vocalisations but also to other notable changes in child’s attention, play behaviour or facial expression [26]. In particular, regarding timing and quality parents intuitively finetune their responses [8]. To be raised by parents who offer a highly responsive parenting style has been shown to be beneficial for many developmental domains, such as language, cognitive, emotional and social development [26]. Responsive maternal behaviour has been found to have a positive effect for the child’s development, whereas an overstimulating, directive and controlling parenting style is associated with lower developmental outcomes [26,28,30]. Consequently, many parental programmes focus on enhancing parental responsiveness as a key area for parents of children with a developmental delay or risk for a delay [26]. Programmes that focus on enhancing parental responsiveness are labelled as

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responsive parenting programmes [31]. Before further reporting on these programmes we will look at the effect that the diagnosis of a HL can have on parenting style. 1.3. Parental responsiveness in communication with children with HL In principle, hearing parents of children with profound HL also show responsive behaviour [6,32–34]. However, the following qualitative differences in their interaction with their children, when compared to parents with normal hearing children, have been found. Their parenting style is more intrusive and directive and these parents tend to be less flexible during the interaction [32,33,35]. The interaction shows less reciprocity [32,33,36,37] and parents tend to be overstimulating, for example by frequent presentation of noise-making toys [38]. The establishing of joint attention is less successful than in dyads of hearing mothers and their children with NH [36,39]. Similarly, qualitative differences in responsiveness are also reported in interactions of hearing parents with preverbal and early verbal infants. Parents of a child with profound HL show less ‘‘dialogic echo’’ [34] than parents of a hearing child – which implies they are less responsive to the child’s vocalisation and early verbal signals [34]. Koester and Lahti-Harper [6] found that parents had fewer vocal imitations in interaction with infants with profound HL aged between 9 and 18 months when compared to hearing dyads. Evidence for the crucial and predictive role of parental sensitivity for the language development of children with HL has already been presented by Pressmann et al. [40]. This study acknowledges the importance of supporting the parents as the most important caregivers of the child [10,16,41]. 1.4. Teaching responsive parenting Looking at current early intervention programmes, there is a general paradigm shift with respect to the underlying principles. Firstly, the role of the child in early intervention settings has changed from a passive, trained object to an active partner in parent–child interactions. Secondly, parents are now empowered to take the central role in their child’s development by reinforcement of their intuitive abilities and resources [16,26,28,31,42–46]. The aim of early intervention is to empower parents to communicate with their children by using a highly responsive style. Consequently, counselling parents needs to focus on everyday parent–child interaction [16,26,38,47,48]. Several responsive parenting programmes for different target groups have been developed, such as:  for hearing children with language delay (toddler and preschoolage): the Hanen Early Language Program: It Takes Two To Talk (ITTTT) [44,48]; the Responsiveness Education/Prelinguistic Milieu Teaching (RE/PMT) [46]; Schritte in den Dialog [45];  for hearing children with developmental delay (developmental age 2–4 years) the Relationship Focused Intervention (RFI) [49,50];  for hearing infants with very low-birth weight following prematurity: the Playing And Learning Strategies Programme (PALS I – infancy: age 6–13 months [43]; and for refreshing PALS II – toddler-preschool: age 30 months [31]);  for hearing children with autistic spectrum disorder: the Hanen Program: More Than Words [51]. The contents and instructions of the above mentioned programmes are based on similar key aspects of responsiveness: to learn to follow the child’s interests by becoming sensitive to their focus of attention, to respond contingently to the child’s communicative signals (e.g. by mirroring), to become aware of turn-taking as a basic dialogue rule, and to provide linguistic input that on the one hand suits the

developmental stage of the child and on the other hand offers a dynamically expanding feedback to support further development [22,26]. Only PALS I [43], like the MPP, focuses on facilitating parental responsiveness towards the preintentional and presymbolic infant already in the first year of life. Some programmes also aim at supporting parents in transferring responsiveness to dialogic picture-book reading [31,44] which has been repeatedly shown to have a positive influence on the child’s developmental outcome [52–54]. The curriculum of the MPP includes core elements of the responsive parenting programmes described above. It combines parental group sessions without children with individual single parental training sessions with child and is delivered within 11 sessions. Looking at the relation between duration and effectiveness of early educational intervention, Bakermans-Kranenburg et al. [27] summarise that ‘‘less is more’’, but stress the importance of a clear educational focus. Their meta-analysis reveals an intervention with the duration of 16 sessions on average to be the most effective. Brady et al. [26] reviewed 10–12 sessions to be sufficient for a responsive parenting programme. Teaching responsive parenting in groups should also consider the ideal group size with respect to parents feeling comfortable and to promote dynamic sharing and learning. In the literature on group teaching programmes for parents of infants and children with communication disorders, the recommended group size varies from 5 to 10 families in the Heidelberg Parent-based Language Intervention (HPLI [52]) to 4–8 in the Hanen Program ITTTT [55]. However, the actual number varies due to the effort for the didactics that are specific to each programme. The MPP is conceptualised ideally for 4– 6 families, but can be provided to a minimum of three families. The participation of both parents is recommended. A limiting factor for conducting larger groups is that the interspersed single training sessions for both parents have to be manageable. Moreover, one characteristic of the MPP is, that it starts ideally three months after identification of HL at the maximum. Parental responsiveness is strongly related to the child’s communicative signals, which underlie large changes over the course of early infancy. Natural parental responsiveness includes a gradual adaptation that facilitates the child’s development from preintentional preverbal communication to intentional verbal communication using multiword combinations [56]. Can parental responsiveness be taught in a way that accommodates the wide range of changing communicative signals in child development? Landry et al. [31] demonstrated that basic training of parental responsiveness towards the preverbal infant in early infancy (6–13 months) combined with a consolidation of parental responsiveness towards the toddler at an early linguistic stage (30 months) increases the impact of the intervention. Based on these findings, the MPP combines parental support in the preverbal stage of the infant (3–18 months) with an individual refresher training session at the early linguistic stage (24–30 months) focusing on dialogic picture book reading. In this refresher training, parents are supported in adapting responsive parenting to the verbal level of their child. The adaptations include verbally enriched corrective and expanding feedback strategies, which have proved to be crucial for successful language development in children with HL [57,58]. In addition, an expanded use of words describing emotions and the verbal reflection about emotional states of the characters in picture books are recommended to help prevent the known risk for children with HL to have a reduced vocabulary for social emotional requirements and a delay in developing theory of mind [59]. To comprise, an intervention concept encompassing the whole transition from preverbal to verbal communication has to convey the documented changes in parental behaviour from intuitive parenting to the more language specific child directed speech [60]. The MPP facilitates parents in this process.

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Looking at the didactics chosen for parental programmes to empower and support parents, two different usages of video are found to be effective means of intervening [27]. On the one hand, the usage of video demonstrations that show other affected parents in a similar life situation reveals itself to be significantly effective in supporting parents to cope with their own life situation [27]. On the other hand, video feedback reveals itself to be significantly effective in enhancing parental responsiveness [27]. Well-known intervention programmes in which video feedback is a core element are, for example, the Hanen Program [44,48], STEEP (Steps Towards Effective Enjoyable Parenting) [61] and Marte Meo [62]. In these programmes the parent and child are video-taped during everyday situations usually at their home. The MPP incorporates both video demonstrations and video feedback. Video demonstrations are used in the group sessions. This offers the opportunity for the participants to observe other (mostly) hearing parents communicating with their children with HL successfully in the preverbal and verbal stages of language development. Simultaneously these video demonstrations serve to illustrate the theoretical aspects of responsiveness. Video feedback is the key means of intervening in the single training sessions of the MPP. It supports parents in transferring the theoretical instructions of the parental group sessions to the interaction with their own child. The MPP also makes use of role modelling using ‘‘guided observation’’ [63]. Here, parents are given the chance to observe their own child interacting with the professional, who consistently reacts responsively as outlined throughout the programme. Parents themselves wish for role models [57] to reflect their own parenting style. Both aspects of using video in the MPP aim at (re-)building confidence in parents’ own resources and skills and at sharing of experiences with other affected parents. Additionally, the providing of space for reflecting upon their own thoughts and feelings regarding their infant with HL with the trainer in single training sessions or with other affected parents in the group sessions aims at lowering parental stress and burden. The timing of the intervention in relation to a child’s age was found to be crucial. Bakermans-Kranenburg et al. [27] showed that interventions that begin at birth are slightly less effective than those that begin 6 months after birth or later. Since UNHS, the babies are usually younger than 6 months when parents receive the diagnosis. On the one hand, mother and newborn should be given time to adapt physically and mentally to the postnatal situation. During the first months, the adaptation and binding to the new family member has priority and should experience as few interruptions as possible. On the other hand, support is required shortly after diagnosis. The MPP is therefore provided for families directly after the confirmation of the HL, but starts at the earliest at three months after birth. 1.5. Communication-oriented approaches for children with HL A supportive environment, the parents’ confidence in their own competence and skills, and the adaptation towards a family member with a high risk for a communication disorder are important factors in empowering parents of children with HL [10,13,41]. Communication-oriented approaches like the Nottingham Approach [33,64], the CHIP (Colorado Home Intervention Program) [15,65], its Austrian adaptation FLIP (Linz Family Centred Intervention Programme) [13] and Natural Auditory Oral Approaches [19,66] are family-centred and concentrate on empowering parents to communicate successfully with their children as an important foundation for their language development. Whereas the Natural Auditory Oral Approach aims at supporting oral language development exclusively [19,66,67], the three other approaches additionally are open to all communication modalities, signing included [13,15,33].

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The MPP also follows communication-oriented principles, concentrates on oral language development, and links these aspects with core elements of responsive parenting programmes. All participating parents communicate orally and have NH in the majority. So their intuitive parental communicative resources base on spoken language experience. Hence the MPP stands closest to the Natural Auditory Oral Approach. The MPP provides parents with evidence-based insights into oral language development in children with or without HL and characterises the importance of a good parent–child communication in daily situations [20,68]. The MPP conveys to parents that gestures have a natural and important role in the preverbal stage, and that they are a prerequisite of oral language and sign language acquisition [69,70]. In this way, the MPP stresses that the preverbal stage is the common basis of both, oral language and sign language, for the overall language development [69,70]. Harrigan and Nikolopoulos [33] presented a responsive parenting group programme including individual video feedback that was successful in enhancing parental responsiveness and in reducing immoderate use of initiative behaviour in parents of 2- to 6-year-old deaf children following cochlear implantation. However, their concept cannot be easily transferred to parents of infants with identified HL directly after UNHS without adaptation to their special situation. Firstly, the recently confirmed HL has a significant impact on the parents’ current emotional state and, secondly, their infant is at the very early preverbal stage at which his/her communicative signals are much more subtle than they will be only a few months later and the use is still unconscious. Consequently, there is a need for a concept that is specific to parents of infants with HL. Our aim was the development, implementation, and evaluation of a responsive parental programme for parents with infants and toddlers with HL at our clinic. In the following, we introduce the concept of the MPP. For a report on the evaluation of the MPP see Glanemann et al. (this volume). 2. The concept of the Muenster Parental Programme (MPP) 2.1. Main goals The MPP pursues two main goals. Firstly, parents are supported in developing individually optimised communication behaviour towards their preverbal child for creating best possible conditions for the child’s listening and speaking skills. The key strategy the MPP brings out is parental responsiveness. Secondly, the opportunity for early exchange with other affected parents aims to assist in lowering parents’ experienced stress and burden. The concept of the MPP has three key features:  It is family-centred in that the participating parent is the person to whom the infant relates most closely.  The MPP combines parental group sessions with individual counselling that is supported by video feedback.  The concept follows the principles of normal language acquisition in terms of a natural interaction-based auditory-oral approach and responsive parenting intervention. The goal of the MPP concerning the child is to facilitate the communication mode that best suits the child’s potentials. We favour the development of oral language including natural gesturing as a principle of normal language acquisition. 2.2. Qualification of trainer The MPP is conducted by a certified MPP-trainer. This certification can be obtained by professionals with sufficient pre-experience in counselling parents of infants with HL after completing the certified 5-day MPP trainer-course (provided since 2012 at our clinic).

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2.3. Target group The MPP is targeted to address parents of children with moderate to profound HL who require one or two hearing devices. Children with unilateral HL have a far lower risk of speech and language delays than children with bilateral HL. However, these parents are also worried about their child’s development, which might affect their intuitive communication. Even in instances of mild HL where the infant has been fitted with hearing aids, parents are welcome to partake in the group. In our experience, it is not the degree of the HL but the individual handling of the diagnosis that distinguishes parents’ preference to seek intervention. Infants aged between 3 and 18 months are included and, if older than 12 months, they are still at the presymbolic one-word-stage (using only some first words). The MPP is also suitable for parents of children with additional developmental or medical conditions (such as conditions after cytomegaly infection, syndromes or developmental delays). However, the MPP-trainer should arrange balanced parent groups with respect to their children’s developmental potential. An MPP-group consists ideally of 4–6 families, but can be provided to a minimum of 3 families, if larger group sizes are not possible. The participation of both parents is recommended even though this is an organisational challenge for the family. Nevertheless, our experience is that in 16% of the families who partook in the MPP, both parents were participating members. In each of these cases the child with HL was their first child. In many instances, the mother was the only participant but some fathers took the offer to accompany mother and child to the single training and counselling sessions (without getting video feedback). Our experience is, that in most of the cases a group comprises 4–6 participants, but never less than 3 and never more than 8. Note that the size of our parent groups is influenced by two interests. Firstly, there is the ideal size of 4–6 families as described above. With this group size, effectiveness with regard to time, costs and benefit for the parents is given. Secondly, however, as a preventive action, the MPP wants to support families preferably close to the time of identification of HL. Therefore, we limit the time of collecting families for a group to three months. Although the minimum group size of three participants questions time and cost effectiveness at the moment of conducting the MPP, the potential of better developmental outcomes of the infants of participating parents may reduce the costs of further treatment. There are only two exclusion criteria for participating in the MPP; one is related to the child, the other to the parent. Parent– child interaction with a blind child requires a concept that focuses primarily on tactile-based communication. Hence, these families should receive more specific support and cannot participate in the MPP. Furthermore, parents need to have sufficient language skills to partake in the programme (a) with respect to the course’s language (to date: German) and (b) with respect to oral language. They need to have sufficient hearing ability in the instance that they have a HL themselves (support through own portable wireless transmission system is welcomed, but no interpretation services are provided). 2.4. Setting The MPP consists of six group sessions and two single training sessions in weekly intervals flanked by one individual preparatory and one closing counselling session for each family. Additionally, there is one refresher single training session when the child becomes 24–30 months. This refresher occurs following the clinic’s monitoring of the child with HL allowing for individual follow-up support, taking into account the large variability of language development in this period. All 11 sessions are conducted by the

same MPP-trainer. At the preparatory appointment the MPPtrainer becomes acquainted with the parent and the child and explains the procedure and the aim of the course. Beyond this introduction it is important to get an impression of the parent’s worries and expectations. A further aim is to diagnose the status of the child’s general, auditory, and communicative developmental status before and about two weeks after the last group session. The interpretation of the results with respect to (a) infants with NH and to (b) infants with comparable HL is explained to the parents. This is done at the preparatory appointment and at the closing counselling session, both lasting 2 h each. In all sessions of the MPP, space is given to parents to express their sorrow or grief if they feel comfortable to do so. If the MPP-trainer is employed in a clinic, all 11 sessions take place in this clinic. Although individual sessions come closer to everyday life if they take place at the family’s home. This is not feasible for many institutions due to restricted financial and personal resources. However, if it is possible to conduct the counselling sessions and the single training session at the family’s home this is highly recommended. In the group sessions parents participate without their child. Each group session lasts 3 h. The two single training sessions and the individual one-time refresher training session with video feedback last about 1.5 h each. The total time of all MPP sessions comprises 26½ h. Looking at the current situation in Germany, the implementation of the MPP could occur as part of the state-funded special pedagogic intervention that supports families of children with HL up to preschool age. To date the MPP is conducted by specialised certified therapists in a clinical setting and goes hand in hand with the then following special pedagogic intervention. This procedure is recommended until more pedagogues have been qualified to conduct the MPP as a part of the state-funded special pedagogic intervention, optimally coordinated with a clinic offering the following flanking measures (see also [5,71]). These are regular pedaudiological examinations, technical support and the close monitoring of auditory, language and general development. If a child with HL does not reach the milestone of (pre-)verbal communication that would be expected at his/her age despite early fitting with hearing devices and despite his/her parents being empowered through the MPP, parents are then advised regarding further specific support depending on the underlying additional delay. 2.5. Contents As the MPP aims to help parents realise and intensify their repertoire of responsive behaviour, the trainer explains and teaches the underlying principles of shared activity and of engaging in quality interaction. Fig. 1 depicts the four core elements of the MPP, which consist of well-documented and consecutive characteristics of responsive parenting in early dialogues: 1. to create joint attention by following the attentional focus of the child via observing and waiting for the child’s next signal; 2. to react immediately (and consistently) to the child’s communication attempts; by imitating and mirroring the vocal and early verbal signals (‘‘dialogic echo’’ [34]) or non-verbal signals. In other words, it is the child who leads through the interaction. Parents learn that their own voice is an important medium for natural auditory intervention in daily life. 3. to establish turn-taking by learning to wait again and again as a fundamental rule for conversation and for equality in the interpersonal exchange; 4. to respond in an expanding way to the child’s vocal, early verbal and non-verbal offers [28,29] with age-related and enriched input concerning listening and auditory, play and language development (‘‘one-step-ahead’’).

[(Fig._1)TD$IG]

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Fig. 1. MPP’s principles towards responsive parenting in everyday life.

With respect to didactics we have linked the ‘‘Four principles on the way to becoming a responsive partner’’ to verbal and visual iconlike reminders, such as Principle 1: ‘‘joint attention’’ + verbal reminder: ‘‘Take your time to observe and listen!’’ + visual reminder: a clock with oversized eye and ear on the watch-hand (see Fig. 1 for verbal reminders/Parents’ principles). In order to help parents to apply this responsive way of interacting in daily life the MPP provides background information to parents concerning:  the fundamental role of communication and responsiveness for early development;  the interplay between play and symbolic development as a foundation for language;  the developmental steps from preverbal to verbal communication;  the role of dialogic picture-book reading as a particular island of language learning: see Fig. 1. The MPP shares the above aspects with well-known programmes in the field of responsive parenting, such as the Hanen Program ITTTT or PALS [see [26] for overview]. Additionally, to meet the special needs of parents of infants with HL the MPP incorporates – among other aspects – the following components:  basic information on HL and hearing devices (air-conductive versus bone-conductive hearing aids, CI/electromagnetic device), with regard to the specific underlying hearing impairment, and daily care for the hearing devices;  information on the typical early stages of auditory development: awareness, detection, discrimination, identification and comprehension of sounds and speech [72];  empowering parents by strengthening their own parental resources and self-confidence by conveying the four principles in daily situations (see Fig. 1) following the natural auditory oral

interaction-based facilitation of listening skills. The active role of the child while discovering environmental sounds is emphasised. The responsive and naturally exaggerated melodic use of the parental voice as an echo of environmental sounds and of vocalisations of the child, as well as its fundamental impact on listening and language acquisition in children with HL is highlighted;  providing insight into language development in children with diverse degrees of HL according to the current state of science theoretically and via video demonstrations. Explaining the role of gestures in the preverbal stage as a prerequisite of oral and sign language acquisition;  helping to cope with the hearing impairment by (a) empathic listening to the grief and sorrow of the parents by the trainer during all sessions; (b) offering the opportunity to become acquainted with other families and their thoughts and responses to similar life situations in the group sessions (as well as in the valuable coffee-breaks without a trainer); (c) giving space for exchange between the parents and the trainer regarding the received information linked to infants with HL; (d) Introducing the model for processing grief and emotional acceptance of Schmutzler [73] and offering time to exchange feelings and thoughts about the diagnosis and its impact on the family. This all aims to lower parents’ experienced stress and burden; however, the MPP cannot substitute professional psychological support – if necessary, further referrals should be initiated.

2.6. Procedure The timetable and curriculum presented throughout the MPP are shown in Table 1.

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Table 1 Procedure, curriculum and timetable of the MPP. Course session

Content

Preparatory counselling

Topic: Becoming acquainted with the family and anamnestic data of the child and family; information about the hearing loss (HL) and the technical device (material: the MPP parental guiding brochure about HL in children) Topic: Examining and explaining the child’s level of auditory development (LittlEARS – parental questionnaire for auditory development [74], level of communication and development) Topic: timetable of the MPP, organisational information

Parent and child

Group session 1

Why a PARENTAL programme? Introducing the background and theory of the MPP: The Natural Interaction-based Auditory-Oral approach: Background of the MPP Principle 1: Take time to observe and listen! Principle 2: Imitate and follow your child

Parent group

Group session 2

Consolidation of Principle 1 and Principle 2 Principle 3: Take turns with your child! Topic: HL in children – an overview Handling the diagnosis – exchange of experiences

Parent group

Single training session 1

Individual training for Principle 1–3 (video feedback)

Parent and child

Group session 3

Responsiveness: theory and practice Accompany your child every day in learning to listen – theory and practice Topic: Checking the hearing device Accepting the child’s handicap – theory and exchange of experiences

Parent group

Group session 4

Topic: Play is a step on the way to language Principle 4: Include your experience! Topic: Gestures as a path to language

Parent group

Group session 5

Topic: From joint action to dialogues: the stages of communication development Topic: The interplay between communication and other developmental domains Having fun: Nursery rhymes and more

Parent group

Single training session 2

Individual training of Principle 1–4 (video feedback) Parents judge their child’s stage of communication and play development Individual advice concerning the next developmental steps

Parent and child

Group session 6

Parents’ experience with Principle 1–4 Topic: Picture books: Islands of language in daily routine The child’s individual photo-book

Parent group

Closing counselling

Topic: Examining and explaining the child’s level of auditory development (LittlEARS [74], level of communication and development) Topic: timetable of the MPP-refresher

Parent and child

Evaluating and explaining the child’s level of auditory and language development (parental questionnaire-based: FRAKIS [75], LittlEARS [74]) Individual training of dialogic book reading with Principle 1–4 (video feedback) Consolidation of Principle 4: Theory and practice of corrective and expanding feedback at the early verbal level; expanding the use of words to describe emotions

Parent and child

Pause (until the child is 2 years old) Refresher single training session 3

2.7. Didactics Our choice of didactics includes a high level of parental participation, as this factor was identified to be critical for effectiveness [14,15]. In the group sessions, each new topic is conveyed through information delivery and practical experience. In the single training sessions, parents are supported in transferring and individualising these hallmarks of successful parent–child interaction with their own child. Video feedback is a core component of the single training sessions. 2.8. Special didactics in group sessions We use introductory games to prepare and attune the parents to the respective topics. The games enable parents to link their own experience with the situation of the child: e.g. Introductory game of the MPP ‘‘Strange sounds in the jungle’’ for the topic ‘‘Accompany your child every day in learning to listen’’: We ask parents what kind of help they would like to get from a guide on their first safari regarding the strange and diverse sounds in the jungle. Mostly they wish the guide to make the animals and their sounds familiar to

them. Looking then at the developing listening skills of their children they find out that detecting a sound without knowing its respective origin is not supportive. Parents should perceive their important role to be a guide through ‘‘the jungle of environmental sounds in daily life’’ for their child. Information is delivered through short lectures and video demonstrations. Presentation of videos increases parents’ understanding of the taught principles and offers the opportunity to experience other parents communicating with their child with HL. For practice and in order to try out the newly acquired principles we use self-reflection, pair or group tasks or experiences, exchange and discussion in the group. We also estimate the communicational developmental level of a child via video and collect ideas in the group for ways that a parent in the video could continue the interaction considering Principle 2 (imitating) or Principle 4 (expanding). Parents receive a little homework for practice and a parental handout after every session to consolidate learned contents. In this way the parent who is not joining the programme can be involved by reading the handout and discussing the content with their partner, too.

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2.9. Special didactics in single training sessions In single training sessions, parents are video-taped 2–3 times in short interaction sequences (3–5 min) with their child. By watching each sequence together immediately after it was filmed the trainer makes the parent aware of his/her intuitive skills. Moreover the trainer encourages the parent’s additional effort to support parent–child communication via the four principles learned in the group. The reviewing of the video raises the parent’s awareness of his/her interactive behaviour. It is crucial for the trainer to have a positive and encouraging attitude towards the parent during the entire video feedback. Encouraging every effort of transferring the learned principles to the interaction with the child is the main task of the trainer when working with video feedback. In particular, successful realisations of interactive parental behaviour that follow the four principles are highlighted and very positively commented upon. The positive impact the parental behaviour has on the infant is identified: it may demonstrate more eye contact, more imitations or show more listening, more babbling, more turn-taking. The parent and the trainer discuss and decide together which of the principles the parent may intensify in the next videotaped interaction. Again, both reflect on the interaction by reviewing the video immediately. After working like this with 2–3 video sequences, the trainer gives the parent the opportunity to watch her child playing with the trainer, who consistently applies the four principles. This interaction is also video-taped and reviewed with the parents. Hereby, parents can see how their infant reacts to a consequently responsive partner. Often they realise for example that their child reacts positively to e.g. longer waiting (Principle 1), imitating with exaggerated facial expression or exaggerated voice (Principle 2), or turn-taking sequences lasting longer, when the trainer imitates behavioural aspects of the child. In this sense observational learning with a role model is part of the video feedback. The single training sessions match the individual needs of a parent–child pair. The trainer’s inner pose towards the parents is to encourage them in their communication with their child while also being mindful of both individual resources and limits concerning behavioural modification. In the single training sessions, there is also room for individual questions and problems concerning the education or development of the child and for their individual processing of grief. 2.10. Refresher single training session In the last group session, parents are already provided with information about dialogic picture book reading as a particular island of language learning to be prepared, when their child reaches picture book age. The refresher single training session is offered to every family individually, when the child reaches the age of two years (24–30 months) and normally already has first experiences in picture book reading with his/her parents. Facing the variability of language development that can extend from single words to multiword utterances at this age, the refresher training is adapted to the individual developmental verbal level of each child. For preparing this, at our clinic the refresher single training follows the monitoring of language development of all two-year-old children with HL. If not possible parents should at least evaluate the auditory and language development of their child by completing the parental questionnaires LittlEARS [74] and FRAKIS [75] at home. By explaining the results at the refresher training, the trainer helps the parent to classify his/her child’s speech and language development with respect to stages of language development imparted to the parents in the fifth group session (see Table 1). Based on this developmental classification, the parent is provided with theoretical information about adapting

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responsiveness (especially Principle 2 and 4, see Fig. 1) to the verbal level of his/her child, including corrective and expanding feedback strategies. This information is also delivered in the refresher handout for the parents. To practice these skills, the individual training focuses on transferring the verbally enriched responsive strategies to dialogic book reading, again through use of video-feedback. In addition, an expanded use of words to describe emotions, as well as the verbal reflection about emotional states of the characters in picture books are recommended to support the child’s social, emotional development and theory of mind. 3. Closing remarks Since 2009, the MPP has been implemented in our clinic with ongoing evaluation. Positive effects on the parental responsiveness towards their infants and on the infants’ vocalisation behaviour have been demonstrated (see Glanemann et al., this volume). Participating parents regard the MPP positively in consideration of the setting, the content, the chosen didactics and value high the early exchange with other affected families. To our knowledge, no evaluated concept for parents of infants with HL exists in Germanspeaking countries, which combine group sessions and single sessions with the emphasis on preverbal communication and responsive parenting. The MPP also fulfils the international recommendation to offer these parents hands-on coaching and practice to empower them in using facilitating strategies concerning the language development of their child [57,76]. Ideally, the MPP is a module of comprehensive early intervention by an interdisciplinary networked team for families with early identified infants with HL. In conclusion, the MPP meets the criteria of an effective family-centred module of intervention after UNHS. The programme also addresses families of paediatric CI candidates. It supports them in bridging the time until the implantation and/or can be used as a module of habilitation after implantation. Conflict of interest This research was supported by grants of Cochlear Research and Development Limited, the Sparkasse Muensterland-Ost, the RolfDierichs-Stiftung and the organisation Ho¨rMal! - Hilfe fu¨r das ho¨rund sprachgescha¨digte Kind Muenster e.V. Acknowledgements We thank Stephanie Brinkheetker for enriching discussions on the MPP concept and Claus-Michael Schmidt for valuable suggestions on the manuscript. We also would like to acknowledge the whole interdisciplinary team of our clinic for supporting the implementation of the MPP. Part of this concept of the MPP has been presented at the 10th European Symposium on Pediatric Cochlear Implantation 2011 in Athens. References [1] C. Yoshinaga-Itano, A.L. Sedey, D.K. Coulter, A.L. Mehl, Language of early-and later-identified children with hearing loss, Pediatrics 102 (5) (1998) 1161–1171. [2] T.Y. Ching, K. Crowe, V. Martin, J. Day, N. Mahler, S. Youn, et al., Language development and everyday functioning of children with hearing loss assessed at 3 years of age, Int. J. Speech. Lang. Pathol. 12 (2) (2010) 124–131. [3] A. Young, M. Gascon-Ramos, M. Campbell, J. Bamford, The design and validation of a parent-report questionnaire for assessing the characteristics and quality of early intervention over time, J. Deaf Stud. Deaf Educ. 14 (4) (2009) 422–435. [4] A. Young, H. Tattersall, Universal newborn hearing screening and early identification of deafness: parents’ responses to knowing early and their expectations of child communication development, J. Deaf Stud. Deaf Educ. 12 (2) (2007) 209– 220. [5] C. Muse, J. Harrison, C. Yoshinaga-Itano, A. Grimes, P.E. Brookhouser, S. Epstein, et al., Supplement to the JCIH 2007 position statement: principles and guidelines

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