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Year : 2016  |  Volume : 22  |  Issue : 4  |  Page : 243-247

Combined gestures and auditory-verbal training for comprehension and production of verbs in deaf children

1 Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2 Department of Speech Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences and Health Services, Tehran, Iran
3 Department of Speech Therapy, School of Rehabilitation Sciences, Hamedan University of Medical Sciences, Hamadan, Iran

Date of Web Publication13-Oct-2016

Correspondence Address:
Mohammad Rezaei
School of Rehabilitation Sciences, Hamedan University of Medical Sciences and Health Services, Hamadan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-7749.192135

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Objective: An important factor determining the efficacy of speech therapy for children with severe hearing loss is the type and the method of educating children in the use of speech language items. Given the shortage of golden time for language learning, it is necessary to use efficient speech therapy approaches for improving the language of the child. The aim of this study was to investigate the effect of adding gestures to auditory-verbal training (AVT) in speech therapy for children with severe hearing loss. Methods: In this double-blinded clinical trial, 66 children with severe hearing loss were randomly assigned to two groups of 33 subjects. Receptive and expressive language competence for some simple Persian verbs was evaluated by the Newsha test. The AVT was accompanied by gesture for the intervention group and no accompanying gesture for the control group. Simple verbs include fifty early action words such as sit, run, hold, and go. Results: In both the experimental and control groups, a significant difference was observed for receptive language of simple verbs before and after the intervention (P = 0.001, P = 0.045). However, no significant difference was found before the intervention (P = 0.532), there was a significant difference between mean receptive score of the two groups after the intervention (P = 0.032). Conclusion: Adding gestures to AVT significantly changed the mean expressive score in 2-3-year-old children with severe hearing loss. But, both the synthetic approach and the AVT had the same degree of positive effect for education of receptive language of simple verbs for these children.

Keywords: Auditory-verbal training, Gesture, Severe hearing loss, Simple verb

How to cite this article:
Zamani P, Weisi F, Ravanbakhsh M, Lotfi G, Rezaei M. Combined gestures and auditory-verbal training for comprehension and production of verbs in deaf children. Indian J Otol 2016;22:243-7

How to cite this URL:
Zamani P, Weisi F, Ravanbakhsh M, Lotfi G, Rezaei M. Combined gestures and auditory-verbal training for comprehension and production of verbs in deaf children. Indian J Otol [serial online] 2016 [cited 2021 Jul 30];22:243-7. Available from: https://www.indianjotol.org/text.asp?2016/22/4/243/192135

  Introduction Top

In most children, learning and using a language is totally depended on hearing ability, especially in initial stages of life. [1] Hearing loss can be categorized as mild (26-40 dB), moderate (41-55 dB), moderately severe (56-70 dB), severe (71-90 dB), and profound (+90 dB). [2]

During the period of language learning, if a child suffers from hearing loss, different impairments will occur in the quality and quantity of language learning process. The severity of impairment will depend on different factors such as the rate of hearing loss, the age of occurring hearing loss, the time of beginning to use hearing aid, its duration and intelligence. [3],[4] The problem of hearing loss is very serious because according to global statistics prevalence of hearing loss in newborn babies is about 1-6 in 1000 births. [5],[6] In Iran, the prevalence of hearing loss is estimated about 4.7-7.5 in 1000 births. [7],[8],[9]

Children who suffer from severe bilateral hearing loss are unable to hear usual conversational speech (with intensity of 60 dB). Consequently, they will not naturally learning to speak by hearing others speak during daily activities. Therefore, there is a delay or cessation in the development of expression and comprehension. This is one of the most obvious disorders which results from severe hearing losses. [10] The rate and speed of formation of verbal and nonverbal concepts are weaker in children with severe haring losses compared to their hearing counterparts. [11] Researchers indicated that children with hearing loss (CWHL) suffer from impairment in correct usage of morphemes in verbs, use of adverbs, proposition, conjunction, and other grammatical parts. Even some unusual grammatical structures have been seen in the speech of these children. This may show the fact that CWHL follow their special pattern of grammatical development. [12] Children with severe hearing loss are like hearing children in the way they develop semantic relationships, but it occurs in a more limited manner and at a slower rate and with a smaller volume of examples. [13] Like hearing children who are able to transfer semantic concept via conversations; children with severe hearing loss use sign language to transfer semantic and mental concepts of language to other deaf children. Children with severe hearing loss show great difficulties in comprehension of contentious speech but their problem in comprehension of simple and concrete single verbs is not severe. [10],[11]

Some important issues related to speech therapy of children with severe hearing loss are the type and method of therapies as well as instructional approaches in teaching language items to these children. Treatment approaches for children should be simple and straight forward. In addition, these approaches should contribute to the process of learning language by the children using most natural and influential possible method. Considering the shortness of critical period for learning language, these approaches should enjoy high efficiency and speed. There are some specific techniques for speech therapy in these children including auditory-verbal approach, verbal approach, and sign language approach. Each of these approaches emphasizes one particular sense for learning language. In auditory-verbal approach, the emphasis of language teaching is on the remaining hearing ability of child. Visual signs and guidance as well as lip-reading are not utilized. Treatments are done on individuals by intensive hearing and repetition. The weakness of this approach is that it is only applicable for children who can hear with hearing aid and have used hearing aids or cochlear implants from early ages. [14]

Auditory-verbal therapy is to emphasis the hearing sense in children who have been diagnosed under the age of 6 months. The other sensory modalities (visual and tactile) are not emphasized for the acquisition of spoken language. Moreover, according to the clinical experiences and the findings of some studies, the auditory-verbal approach has not been effective for some children with hearing and the lengthy therapy process will lead to waste of the critical period of language learning. [15],[16] The children who have not gained good spoken language after receiving auditory-verbal therapy are likely to have little benefit from their hearing aid or they have been diagnosed late or have other disabilities as well as hearing loss.

Lim and Simser stated that the auditory-verbal approach is often effective in improvement of language ability in CWHL. But they suggested at least a 6 months therapy period is needed to see its effect on speech abilities. [17] Goldberg and Flexer concluded that the result of auditory-verbal approach can be longitudinal and time consuming. [18]

Consequently, the complement of this approach by adding other sensory guidance and clues is needed for some CWHI and the combination or assimilation of two or more therapy approach can compensate for the shortages and limitations of the auditory-verbal approach.

One of the most salient visual clues or guidance' that can be used in daily communications is gestures. [19] The satisfactory result of this therapy approach has been proven in patients with communicative disorders such as children with Angelman syndrome, [20] speech motor disorders, [21] and different types of aphasia syndrome. [22],[23] Gesture is distinctive in every country and is culture specific; therefore, this study investigated the quantity of gestures appropriate to Iranian culture and Persian speaking society and the study measured the effect in combination with gesture for teaching simple Persian verbs to CWHL.

  Methods Top

A convenience sample was used and children with severe hearing loss were chosen based on the inclusion and exclusion criteria. Second, the agreement of participants of the study was acquired. The total number of participants was 66, and they were randomly divided into two experimental and control groups. The inclusion and exclusion criteria in this study was determined as following hearing loss between 71 and 90 dB, lack of sensory-motor disorders, mental retardation (based on social communicative behaviors), autism, seizures, trauma to the head, hyperactivity, and attention deficiency. There was also a requirement of no more than 6 months of continuous speech therapy and a need to wear a hearing aid for 3 months before the research intervention. All subjects signed informed consent documents and provided background information about their children using case history forms.

In the control group, speech therapy intervention was administered for teaching comprehension and expression of eight simple Persian verbs exclusively by the auditory-verbal approach. These verbs included go, come, sit down, standup, give, were, went, is not. In the experimental group, speech therapy instructions of these verbs were the combination of two methods: Auditory-verbal and visual gestures approach. Hence, for each of these simple verbs, one pantomime gesture which the therapist could perform with one or two hands was designed. During the speech therapy instructions, in addition to expression of the verb and its repetition, the gesture related to that verb was demonstrated for hearing loss children by the therapist. The intervention included 15 intensive sessions of individual speech therapy (three 1-h sessions/week) in which other than instruction, essential counseling was provided for parents to continue the training at home. The process of verb instruction was administrated according to the children's ability, the verbs were divided in three groups. In the 1 st week, three verbs and in the 2 nd week in addition to the training of three previous verbs, the other three new verbs were taught. In the 3 rd week, the learning of first three verbs was established and second three verbs were practiced then the two remaining verbs were introduced. In the 4 th week, the learning of second group of verbs was established and the two final verbs were practiced. Finally, in the last week, the initial six verbs were reviewed and learning of two last verbs was confirmed. In fact, the final evaluation of intervention was postponed to the 16 th session. All of the instructions and learning were administered in two levels of comprehension and expression. It is worth mentioning that because of the similarity of syntactic structures of initial six verbs no consideration was made regarding the order of presentation of verbs. Therefore, the order of presentation was only based on children's interest to learning and their needs in the family. Because of the different syntactic structures of two last verbs (went, is not), these two verbs were introduced in the final stage of therapy. About using of gestures in the experimental group, it should be mentioned that a pilot test-retest was conducted on the consistency of the comprehension of these gestures by thirty 2-3-year-old normal hearing children. Consistency coefficient of responses was 89%. At the beginning of the study, experimental and control groups were evaluated in terms of communicative-social skills by Vineland test, [24] intensity rate of hearing loss (audiogram), and demographic features (questioner). Their responses were compared in order to homogenize the two groups. In case of communicative-social skills of 2-3-year-old children in Vineland test, the score between 74 and 86 is considered normal. [23] Using modified Newsha test with consistency rate more than 92%, [25] language scores related to comprehension and expression of simple verbs before and after intervention were calculated. After determining mean and standard deviation (SD) of language scores from pre- and post-treatment by SPSS version 18 (copyright 1993-2007 Polar Engineering & Consulting, USA). The paired t-test and independent t-test with 95% confidence interval was conducted.

  Results Top

There was no significant difference between the means of ages of two groups (P = 0.530). Both groups were compared on the effective parameters such as the duration of using hearing aid (P = 0.280), the rate of hearing loss (P = 0.332), and communicative-social skills (P = 0.123). There was no significant difference on the comparison [Table 1].
Table 1: Comparison of demographic variables in experimental and control group

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Mean and SD of the scores of simple verbs comprehension in experimental group before and after intervention were 2.52± (0.51) and 4.28± (0.39), respectively. The mean and SD for the control group before and after intervention were 2.62± (0.66) and 3.44± (0.61), respectively. The statistical result indicated that before the intervention there was no significant difference between the means of control and experimental groups in simple verbs comprehension scores (P = 0.532). However, after intervention, there is a significant difference between simple verbs comprehension scores of two groups (P = 0.032).

To conclude, the children in the experimental group who used the combined method, outperformed their counterparts in the control group regarding simple verbs comprehension [Table 2]. On the other hand, in contrast, the within-group comparison showed that in both the combined group (P = 0.001) and auditory-verbal alone group (P = 0.045), there is a significant difference between simple verbs comprehension scores before and after intervention [Table 2].
Table 2: Mean scores of simple verbs comprehension in two groups before and after intervention

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Mean and SD of the scores of simple verbs expression in experimental group before and after intervention were 1.70± (0.47) and 3.21± (0.70), respectively. The mean and SD for the control group before and after intervention were 1.62± (0.51) and 2.19± (0.29), respectively. The statistical result indicated before the intervention there is no significant difference between the means of control and experimental groups in simple verbs expression scores (P = 0.145). Conversely, after intervention, there is a significant difference between simple verbs expression scores of two groups (P = 0.012).

The experimental group who used the combined method, outperformed their counterparts in control groups regarding simple verbs expression [Table 3]. Within-group comparison using paired t-test showed that in the experimental group, there is a significant difference in the simple verb expression scores before and after intervention (P = 0.001), but in the control group, who used the auditory-verbal approach the difference before and after intervention is not significant (P = 0.055) [Table 3].
Table 3: Mean scores of simple verbs expression in two groups before and after intervention

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  Discussion Top

For the comprehension and expression of different words, it is obvious that every child essentially needs hearing sense at the beginning of the language learning process. But the question is if the child is basically deprived of the sense of hearing, should the speech therapist focus their instruction mainly on developing the impaired sense as much as possible as occurs in the auditory-verbal approach. Or should the other sensory abilities such as visual and tactile cues be applied to assist with the development of language. The auditory-verbal approach has had many proponents and has many positive clinical effects. This occurs when children have access to all the speech spectrum sounds as occurs with the use of cochlear implants which by pass the damaged hair cells. But the expectation of parents from language learning and speech therapy approaches is to compensate for delay in the speech ability of the child. Therefore, an approach is more successful and effective when it could give comprehension and expression competence in a shorter time. In the current study, two groups of children with severe hearing loss at the early stages of language learning received two different types of intervention (auditory-verbal combined with gestures) approaches were in acquiring simple Persian verbs.

The findings of the study showed that mean of scores in comprehension and expression of simple verbs for experimental groups who used combined approach after 15 sessions of speech therapy have significantly changed and increased. This increase in control group was observed just in comprehension and their expression ability did not change. Kishon-Rabin et al. confirmed these finding and believed that in comparison with a unitary, combined approach can dramatically affect the comprehension process of children with severe hearing loss. Hence, they suggested speech therapy and auditory training approach use multisensory and combined approach. [26] In similar studies, the addition of lip-reading instructions is recommended. [27] The simultaneous application of multisensory instructions such as audio, visual, and touch [28] was advocated and compared to a unitary approach. Has more significant effect on the improvement of speech ability of hearing loss children. Researchers believed that the improvement of language skills via multisensory instruction is a result of multi-dimensional learning and similarity of instructional methods to natural acquisition of language concepts. [28],[29]

In teaching, the comprehension of simple verbs in the control group of auditory-verbal therapy alone, the findings indicate that the change and clinical effect was significant. There are several studies which confirm the positive effect of auditory-verbal approach on comprehension of children with severe hearing loss providing that the hearing loss of children is diagnosed early, an appropriate hearing aid with high technology is applied, parents are actively contributing to therapy process, the therapy sessions intensive and extensive with regular repetition and auditory imitation are provided for hearing loss children. [30],[31] An interesting point in the findings of the study is observed changes in simple verbs expression of the control group. The results suggested that although the mean of simple verbs expression of the control group has increased this difference is not statistically significant and we can consider this point as a novel outcome. The findings of this study are in line with the results of other studies. Lim and Simser as well as Goldberg and Flexer believed that verbal auditory approach is time consuming and longitudinal and child cannot gain the speech ability in a short intensive and quick period of speech therapy. [16],[17] This idea has been confirmed in Oryadi Zanjani et al., Duncan and Rochecouste study. They believed that speech development and the increase of mean of length utterance of children with severe hearing loss who have been undergone the verbal-auditory therapy are lower than their normal counterparts. [32],[33]

  Conclusion Top

The comparison of these two approaches in this study can provide the researchers more knowledge about the effect of using gestures for the instruction of comprehension and expression simple verbs to children with severe hearing loss.

The findings of this study demonstrate that children with severe hearing loss showed more progress when they were instructed by multisensory and combined approach in shorter time compared to those children who exclusively used verbal-auditory approach.


We are very grateful to Akram Ahmadi for reviewing the original article. Appreciation is also expressed to the children who took part in this study. The research was supported by Ahvaz Jundishapur University of Medical Sciences and Health Services.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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