Parent–Child Interactions in Deafness Children: Comparison
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Please note this is a comparison between Version 2 by Lindsay Dong and Version 1 by Martina Curtin.

Despite early identification and advancements in cochlear implant and hearing aid technology, delays in language skills in deaf children continue to exist. Good-quality parent–child interaction (PCI) is a key predictor for the successful development of deaf children’s signed and/or spoken language. As good-quality PCI is widely acknowledged to be significant for child language development in deaf children, then we must have the necessary tools to assess it. This review answers three questions: Which parent behaviours are assessed in PCI? How are they assessed? And which parent interaction behaviours are positively correlated with deaf children's language skills?

  • deaf
  • parent–child interaction
  • assessment
  • early interaction
  • speech and language therapy

1. Introduction

Much research describes the importance of good-quality parent–child interaction for children’s language development [1]. Parents are seen as the main provider of the social and linguistic stimulation required for successful child language development [2].
Children develop the foundations of language through the ‘serve and return’ of communicative interactions with their caregiver. This happens first through vocal and visual means (exclamations, babbling eye contact, facial expressions, gestures and pointing) and then through language use [3]. Parents scaffold this development through prompts and contingent reactions to their child’s behaviours [4]. These behaviours in turn encourage and reinforce a child’s communicative intentions [5]. For example, relationships have been found between a parent’s responses to child gesture and vocalisation, and child vocabulary development [6].

1.1. Parent–Child Interaction (PCI) and Deafness

Despite earlier identification and advancements in hearing aid and cochlear implant technology, delays in receptive and expressive language skills in deaf children continue to exist [9,10][7][8]. Many studies have found the quantity and quality of parental interaction to be one of the main predictors of deaf children’s language outcomes [11,12,13,14,15][9][10][11][12][13]. Parents who have not yet developed skills in effectively communicating with their deaf child may provide lower-quality language input [16][14], which in turn affects the child’s language development.

To illustrate, studies have reported that hearing parents of deaf children can often be more directive in their interactions compared to deaf parents of deaf children and hearing parents of hearing children [9,17][7][15]. This manifests as increased interruptions to the child’s attention by parents initiating new, unrelated activities [18][16]. Hearing parents also elicit language from their deaf child through requests rather than conversations, meaning deaf children have less experience of two-way interaction and receive less feedback on their communicative attempts [19][17]. An important foundation for language development is joint attention, i.e., two people with a mutual focus. Hearing parents struggle to establish and maintain this behaviour with their young deaf infants [20,21][18][19]. Higher rates of directive behaviours from hearing parents of deaf children [17[15][20],22], are less conducive for maintaining attention. The mismatch of hearing status means that hearing parents need to adapt their communication skills to attain successful joint engagement in by gaining or waiting for the deaf child’s attention before starting to communicate and sequentially shifting attention between the environment/objects and each other. In comparison, deaf parents are using these social engagement strategies at an early age with their deaf infants [23,24][21][22] and we see an earlier tuning in of the deaf child’s gaze [25][23].

1.2. Improving Parent’s Skills in Interaction

Despite the association between parental interaction and child language development, enhancing hearing parents’ communication with deaf children is a complex issue. Parents of deaf children receive multiple home visits and attend appointments for medical and audiological purposes where they learn about deafness, communication, and future education [26][24]. To reduce the communication difficulties that can cause increased family stress [27][25], hearing parents are required to adapt their communication style and often receive family-centred interventions that incorporate new strategies to enhance their interaction skills. The level of parental involvement in these interventions varies and can be associated with acceptance of the child’s deafness, parental self-efficacy, and the amount of support a family receives [28][26].

2. Parent–Child Interactions Assessment in Deafness Children

2.1. Parent Behaviours Are Being Assessed in PCI Studies

32.31.1. Attention-Getting Behaviours

Attention-getting behaviours can be defined as explicit bids, made by the parent, with the intent of gaining or directing their deaf child’s attention. The bid for attention can use one or more modalities. Fourteen (14) of the 61 studies (papers 1 to 14 in Table 1) observed this aspect of parent behaviour. Data from these papers have been synthesised into four modalities: visual, auditory, tactile, and multi-modal.
Table 1. Papers included in the review (n = 61) and the associated research questions.
Paper

No		First AuthorYearReported Country of StudyStudy DesignDegree of Hearing LossNo of DyadsPCI Behaviours AssessedPCI Measure (Method)Child Lang Assessed?Risk of Bias
1Beatrijs. W., et al. [21]2019BelgiumTwo between-groups,

observational studies		No Report13Attention-Getting

Strategies		CodingNModerate
2DesJardin, J. L. [27]2006USAWithin-group,

observational study		Mod–Prof32Attention-Getting Strategies and Parental CommunicationCodingYModerate
3Loots, G. et al. [28]2003BelgiumBetween-groups,

observational study		Mod–Prof33Attention-Getting

Strategies		CodingNLow
4Waxman, R. et al. [29]1997USABetween-groups,

observational study		Mild–Prof77Attention-Getting

Strategies		CodingNModerate
5Chasin, J. et al. [30]2008UKBetween-groups,

observational study		Profound9Attention-Getting Strategies and Child Eye GazeCodingNModerate
6Harris, M. et al. [31]1989UKWithin-group,

longitudinal

observational case series		Profound4Attention-Getting

Strategies and Child Eye Gaze		CodingYSerious
7Harris, M. et al. [32]1997Australia and

UK		Between-groups,

observational study		Profound11Attention-Getting

Strategies and Child Eye Gaze		CodingNCritical
8Harris, M. et al. [32]2005UKBetween-groups,

observational study		Profound26Attention-Getting

Strategies and Child Eye Gaze		CodingNModerate
9Lederberg, A. R. et al. [33]1998USABetween-groups,

observational study		Sev–Prof40Attention-Getting Strategies and Child Eye GazeCodingYModerate
10Prendergast, S. G. et al. [34]1996USABetween-groups,

observational study		Sev–Prof16Attention-Getting Strategies and Child Eye GazeCodingNModerate
11Gabouer, A. et al. [35]2018USABetween-groups,

observational study		Sev–Prof18Attention-Getting Strategies and Joint EngagementCodingNSerious
12Loots, G. et al. [22]2005BelgiumBetween-groups,

observational study		Mod–Prof31Attention-Getting Strategies and Joint EngagementCodingNLow
13Nowakowski, M. et al. [36]2009CanadaBetween-groups,

observational study		Sev–Prof56Attention-Getting Strategies and Joint EngagementCodingYModerate
14Tasker, S. et al. [37]2010CanadaBetween-groups,

observational study		Sev–Prof53Attention-Getting Strategies and Joint EngagementCodingYLow
15Barker, D. H et al. [7]2009USABetween-groups,

observational study		Sev–Prof185Joint EngagementCodingYLow
16Cejas, I. et al. [8]2014USABetween-groups,

observational study		Sev–Prof276Joint EngagementCodingYModerate
17Roos, C. et al. [38]2016SwedenWithin-group,

observational study		Sev–Prof12Joint EngagementCodingNModerate
18Spencer, P. E. [39]2000USABetween-groups,

observational study		Mod–Prof80Joint EngagementCodingNSerious
19Dirks, E. et al. [18]2019The NetherlandsBetween-groups,

observational study		Mod51Joint Engagement and Parental SensitivityExisting Scale + CodingYLow
20Gale, E. et al. [40]2009USABetween-groups,

observational study		Sev–Prof15Joint Engagement and Parental SensitivityCodingYModerate
21Janjua, F. et al. [41]2002UKWithin-group,

observational study		Sev–Prof13Joint Engagement and Parental SensitivityCodingYSerious
22Lederberg, A. R. et al. [42]1990USABetween-groups,

observational study		Mild–Prof82Joint Engagement and Parental SensitivityNovel Scale + CodingYModerate
23Meadow-Orlans, K. P. et al. [43]1993USABetween-groups,

observational study		Mod–Prof80Joint Engagement and Parental SensitivityNovel Scale + CodingNModerate
24Meadow-Orlans, K. P. et al. [16]1996USABetween-groups,

observational study		Mod–Prof80Joint Engagement and Parental SensitivityNovel Scale + CodingNModerate
25Abu Bakar, Z. et al. [44]2010Not reportedBetween-groups,

observational study		Sev–Prof18Parental SensitivityNovel ScaleNSerious
26Meadow-Orlans, K. P. et al. [45]1995USAWithin-group,

observational study		Mild–Prof43Parental SensitivityNovel ScalesNModerate
27Lam-Cassettari, C. et al. [46]2015UKBetween-groups,

intervention study		Mod–Prof14Parental SensitivityExisting ScaleNModerate
28Meadow-Orlans, K. P. [47]1997USABetween-groups,

observational study		Mod–Prof40Parental SensitivityNovel ScalesNModerate
29Pressman, L. J. et al. [48]1998USABetween-groups,

observational study		Mild–Prof42Parental SensitivityExisting ScaleYModerate
30Pressman, L. J. et al. [49]1999USABetween-groups,

observational study		Mild–Prof24Parental SensitivityExisting ScaleYLow
31Spencer, P.E. [50]1996USABetween-groups,

observational study		Mod–Prof43Parental SensitivityNovel ScaleYLow
32Vohr, B. et al. [51]2010USABetween-groups,

observational study		Mild–Prof58Parental SensitivityExisting ScaleYLow
33Waxman, R. et al. [52]1996USABetween-groups,

observational study		Mod–Prof30Parental SensitivityCodingNModerate
34Ambrose, S. E. [53]2016USABetween-groups,

observational study		Mild–Prof48Parental SensitivityCodingYLow
35Caissie, R. et al. [54]1993Not reported.Between-groups,

observational study		Sev–Prof11Parental SensitivityCodingYSerious
36Eddy, J. R. [55]1997AustraliaBetween-groups,

observational study		Sev–Prof18Parental SensitivityCodingYSerious
37Glanemann, R. et al. [56]2013GermanyBetween-groups,

intervention study		Mod–Prof29Parental SensitivityCodingYModerate
38Wedell-Monnig, J.; et al. [57]1980USABetween-groups,

observational study		Sev–Prof12Parental SensitivityCodingNSerious
39MacTurk, R. H. et al. [58]1993USABetween-groups,

observational study		Mod–Prof40Parental Sensitivity and Child Eye GazeNovel ScalesNSerious
40Choo, D. et al. [59]2016AustraliaWithin-group,

observational study		Sev–Prof12Parental Sensitivity and Parental Communication (Comm.)Novel ScaleNModerate
41James, D. et al. [60]2013UKWithin-group,

intervention study		Profound3Parental Sensitivity and Parental Comm.Existing Scale + CodingYSerious
42Nicastri, M. et al. [11]2020ItalyBetween-groups,

intervention study		ProfoundNot reported: 22 parents of 14 childrenParental Sensitivity and Parental Comm.Existing ScaleYModerate
43Preisler, G. M. [61]1995SwedenWithin-group,

observational study		No Report14Parental Sensitivity and Parental Comm.CodingNSerious
44Quittner, A. L. et al. [12]2013USABetween-groups,

intervention study		Sev–Prof285Parental Sensitivity and Parental Comm.Scales (×2 existing, ×1 novel)YLow
45Quittner, A. L. et al. [62]2016USABetween-groups,

observational study		Profound285Parental Sensitivity and Parental Comm.Scales (×1 existing/×1 novel)YLow
46Ahmad, A. et al. [63]2016AustraliaBetween-groups,

observational study		Mild–Prof16Parental CommunicationCodingNModerate
47Brown, P. M. et al. [64]2004AustraliaBetween-groups,

observational study		Profound20Play and Parental CommunicationCodingYModerate
48Chen, D. [65]1996USABetween-groups,

observational study		Mod–Prof12Parental CommunicationCodingYSerious
49DeVilliers, J. et al. [66]1993USAWithin-group,

observational study		Profound2Parental CommunicationCodingNCritical
50Morelock, M. et al. [67]2003USA/AustraliaBetween-groups,

observational study		Profound9Parental CommunicationCodingNSerious
51Roberts, M. [68]2019USARandomised controlled trialMod–Prof19Parental CommunicationCodingYModerate
52Koester, L. S. et al. [69]2010USABetween-groups,

observational study		Mod–Prof61Parental CommunicationCodingNSerious
53Paradis, G. et al. [70]2015USABetween-groups,

observational study		No Report60Touch and Parental SensitivityExisting Scale + CodingNModerate
54Pipp-Siegel, S. et al. [71]1998USABetween-groups,

observational study		Mild–Prof48Touch and Parental SensitivityExisting Scale + CodingNModerate
55Abu-Zhaya, R. et al. [72]2019USA.Between-groups,

observational study		Mild–Prof24TouchCodingNModerate
56Gabouer, A. et al. [73]2020USABetween-groups,

intervention study		Sev–Prof18TouchCodingNSerious
57Spencer, P.E. [74]1993aUSABetween-groups,

observational study		Mod–Prof36Other: Maternal Comm. ModalityCodingYLow
58Spencer, P.E. [75]1993bUSABetween-groups,

observational study		Mod–Prof7Other: Maternal Comm. ModalityCodingYModerate
59Lederberg, A. R. et al. [76]2000USABetween-groups,

observational study		Sev–Prof40Other: Maternal Comm. ModalityCodingYModerate
60Depowski, N. et al. [77]2015USABetween-groups,

observational study		Sev–Prof8Other: Type and Use of GestureCodingNSerious
61Lieberman, A. et al. [78]2014USABetween-groups,

observational study		Mod–Prof8Other: Maternal and Child Eye GazeCodingYModerate

Visual Strategies

Using any of the following within the child’s visual field with the intention to gain or direct the child’s attention: waving, gesturing, reaching, pointing, making eye contact, switching gaze between an object and the child, holding or moving an object or toy directly into the child’s visual field, offering an object, manipulating an object, demonstrating play with toys, making faces, displacing the location of a sign into the child’s vision or signing space, and changing affect.

Auditory Strategies

Using any of the following sounds to gain a child’s attention: using voice to call the child’s name, using a word such as ‘look!’ or non-words (e.g., ‘whee’ or ‘pssst!’), humming or singing; use of the body to make sounds (outside of the child’s visual field) such as clapping or clicking; and/or the use of toys or objects to make sounds.

Tactile Strategies

Using any of the following to gain or direct a child’s attention: making gestures or signs on the body of the child; tapping, touching, hugging, or holding the child; grabbing on to the child’s clothing; moving the child’s limbs; and touching the child with a toy (out of their visual field). This category also includes tapping the ground to create vibrations, and physically adjusting the child’s position to direct their attention.

Multi-Modal Cues

Combinations of the above—multi-modal cues—were also coded. For auditory-visual combinations, a parent might say ‘uh oh!’ and gesture as a toy rolls under the table. For visual-tactile, a parent may turn a child sat on their lap and then point to a new toy out of their current visual field. Other combinations may be auditory-visual-tactile, e.g., holding a child while talking to them and pointing to a toy.
Coding in papers that included deaf parents of deaf children also featured ‘waiting’ as an attention-getting strategy [1[1][3][10][15],3,12,17], e.g., it was noted when parents did not initiate the interaction or any expression but actively waited until their child was looking at them before communicating. This could be seen as an attention-getting strategy, as a paused action may warrant the child to look towards the parent. These papers also put greater focus on parents’ visual-tactile attention-getting strategies (ibid).
Related to interaction, six studies (papers 5–10 in Table 1) reported on the success of parental attention-getting behaviours in relation to child gaze and noted gaze could be either elicited, responsive, spontaneous, and failed.
Papers 11 to 14 in Table 1 combined attention-getting behaviours with joint engagement between parent and child. This phenomenon was the focus for many more papers included in this review and is defined and described in the next section.

31.31.2. Joint Engagement

Joint engagement is a state of mutual focus and shared involvement between a parent and child, where both participate in reciprocal, contingent, socially directed behaviours. Authors use the following terms interchangeably: joint engagement, joint attention, and intersubjectivity, with frequent references to the coding systems of Bakeman and Adamson [93][79], Prezbindowski and colleagues [94][80], and Tasker and Schmidt [95][81]. Twelve of the studies observed this phenomenon (papers 11 to 24 in Table 1).

When Engagement Is Established and When It Is Terminated

Marking joint engagement as ‘established’ varied from three seconds of mutual focus to a five-second rule of engagement (where the child had to respond to a parent’s act within five seconds). It was also categorised as three or four sequential, on-topic, connected turns where both the parent and child’s attention and/or language are focussed on the same event or object. Physical acts were also included (such as tickling or laughing). Similarly, how to class a state of joint engagement as finished also varied across papers. Joint engagement was ‘terminated’ when one social partner stopped responding and their attention was lost after a set time period which varied between papers from 3 to 15 s.

Levels of Joint Engagement

Some authors differentiated between ‘supported/passive’ joint engagement, with the parent joining the child in an activity and helping to support the joint engagement, without the child acknowledging the parent, and ‘coordinated’, wherein both parent and child exclusively engaged with each other and the activity. Interactions may be physical and/or visual (body movements, facial expressions, tickles) or may be ‘symbol-infused’, which refers to the use of language (signed, spoken or referential gesture) within a period of joint engagement.
The authors of the current review use ‘joint engagement’ as the term suggests parent and child are active participants, doing more than simply attending to the same thing.

32.31.3. Parental Sensitivity

Parental sensitivity refers to a set of skills that enables a parent to be emotionally connected, in tune and responsive to their child’s needs, goals, and communicative attempts. A parent with a high level of sensitivity will be positive and accepting of their child and will strive for interactive congruence. Twenty-five (25) studies within the review assessed this aspect of parent behaviour (papers 19 to 45 in Table 1) and therefore it is the most frequently assessed aspect of PCI. Across papers parental sensitivity was described as a group of sub-skills. Parents were often assessed on each of these sub-skills using Likert-scales. These behaviours consisted:

Positive Regard

A parent showing enthusiasm, warmth, pleasure, love, and respect for their child, regularly using positive body language, praise and comforting and playful physical touch. Opposite: Covert or overt hostility, negative affect, physical harshness.

Availability

A parent who is genuinely interested and actively involved in participating in accessible interactions with their child. Opposite: Passive, bored, and disengaged.

Contingent and Responsive

A parent that follows their child’s lead and pace and responds with contingent, on-topic behaviours or language. Opposite: Directive, intrusive, dominant, and regularly initiating new topics.

Emotionally Sensitive

A parent who is emotionally attuned and adaptive. Able to recognise and respond to distress and disinterest, and repair or resolve misunderstandings or conflict. Opposite: Lacking or unhelpful emotional responses, unwillingness to soothe or resolve incidents causing discomfort.

Structure and Stimulation

A parent who is able to support a child’s interest by guiding and developing the interaction with appropriate play and language. The parent will be flexible and accept a change in play or routine put forward by the child. Opposite: Overpowering, structuring the play, inappropriate pace or activity, highly authoritative, inflexible, or formally teaching the child.

Consistency

A parent who can absorb a range of child emotions and behaviours, whilst remaining mostly constant in their behaviours, predominantly striving for a positive interaction. Opposite: Unpredictable behaviour that changes regularly in the interactions from positive to negative.
Most of the papers also included a rating of the child’s levels of responsiveness (also termed compliance or eagerness to respond) and involvement (initiations made, willingness to share). Some codes and scales rated the dyads for overall synchronicity, reciprocity, enjoyment, and communicative competence (understanding of one another). Papers 39 to 44 assessed parental sensitivity along with parental communication behaviours.

32.31.4. Parental Communication Behaviours

Parental communication behaviours are language-focused strategies used by parents during moments of interaction with their deaf child. Though most are explicitly linked to exposing the child to signed or spoken language, some behaviours are centred around increasing the child’s access to spoken or signed language. Papers that only recorded and analysed parent’s verbal interactions were excluded (n = 43) and are listed in Appendix C. Thirteen papers assessed parents on a range of communicative behaviours (papers 40–52 in Table 1) and these are summarised below:
Increased access to language: Some papers assessed parents on their ability to communicate within the child’s line of sight or whilst being face to face; others observed parents’ use of timing, i.e., waiting for the child to look before communicating. Others observed parents’ use of child-directed speech or child-directed sign, i.e., where parents modify their speech or sign to be more child orientated. For example, a parent may adapt the palm orientation of a sign so the child can see more of the hand; they may increase the size and range of movement of signs, they may exaggerate the non-manual features of accompanying signs (facial expressions), use exaggerated vocal pitch or acoustic/sign highlighting, where the parent adapts their amplification of words or signs closer to the child.
Language input: This category refers to signed or spoken languages. Similar to parental sensitivity, parents were assessed on their contingent talk and number of connected turns, as well as their off-topic initiations (i.e., directives, requests and questions). Parents’ use of language stimulation was coded and assessed on how they: labelled items or feelings; commented; described; made accompanying sounds; interpreted their child’s behaviour with language; repeated their child’s utterance; expanded their child’s language by adding 1 or 2 new words, or rephrased it with correct grammar. Parents’ mean length of utterance (MLU) was assessed in one paper. Parents’ use of praise, affirmation and encouragement was assessed through language use, intonation, their gesture, and facial expressions. Assessment of less frequent behaviours included the parent modelling play, and the parent opposing the child, either by rejecting their communication, correcting their communication, or prohibiting their child’s behaviour.

32.31.5. Use of Touch

The frequency and function of parents’ use of touch when interacting with their child was also assessed in a small set of studies (Papers 53–56 in Table 1). The authors of these papers were interested in the type, location, and duration of parent-initiated touch. One paper looked at the temporal alignment between touch and parents’ utterances [85][72]. Two papers also measured parental sensitivity [83,84][70][71] with Paradis and Koester [83][70] creating a coding system to analyse the function of parental touch, e.g., affectionate, attention-getting and instructive.

32.31.6. Other

Five papers included in the review sit within this category (papers 57–61 in Table 1). Three papers [87,88,89][74][75][76] focused on the communication mode of parents (i.e., how often they signed, used gesture or spoke). One paper looked in detail into the type and function of gesture used [90][77] and another transcribed American Sign Language and documented eye gaze between mother and child [91][78].

2.2. Parent Behaviours Assessed

Most papers (66%, n = 40) used a coding system to assess PCI, often watching and coding films frame by frame, using software such as INTERACT (Mangold) and ELAN (Max Planck Institute). This method allowed an in-depth analysis of the behaviours focused on in RQ1. Thirteen (13) papers (22%) used Likert scales instead of coding and some scales were well-known and validated, while others were developed for the specific research study with little mention of pilot testing prior to their use. The Emotional Availability Scales [96][82] were used in 7 of the 11 papers that used validated scales. Nine papers (12%) used a combination of coding and scales. See Table 2.

Table 2.
Methods of assessing PCI between included papers.
Method of Assessing PCI
n Papers (%)
Coding 40 (66%)
An existing, validated scale 7 (12%)
A novel scale 4 (7%)
A mix of validated and novel scales 2 (3%)
Coding and a validated scale 4 (6%)
Coding and a novel scale 4 (6%)

2.3: Which Parent Behaviours Are Associated with Higher Child Language Scores?

2.3.1. Joint Engagement

Higher child language scores were related to more time in higher level engagement states with a parent (i.e., coordinated joint engagement and symbol-infused joint engagement) [10][8]. Deaf children spent significantly less time in these states when compared to their hearing peers and therefore used less language [9,55][7][40].
Dirks and Rieffe [20][18] add further evidence to this finding: deaf children and their hearing parents are less successful in establishing joint engagement and have briefer episodes when they do. These authors found positive correlations between total duration of joint engagement and receptive and expressive language skills. Interestingly, Gale and Schick [55][40] and Dirks and Rieffe [20][18] found correlations between non-intrusiveness and joint engagement in mothers who followed their toddler’s interests, rather than directing, and this was also linked to more instances of joint engagement.

2.3.2. Parental Sensitivity

Maternal sensitivity was positively correlated with expressive language and predicted language growth over time [14,76][12][62]. In their study of 285 deaf children with cochlear implants, Quittner and team found parents with above-average skills in maternal sensitivity and language stimulation had children with 1.52 years less of a language delay [14][12]. Dirks and Rieffe [20][18] also found positive relationships between parental sensitivity and receptive and expressive child language and total duration of joint engagement. Children with better language experienced longer interactions with their parents and this was linked to parents with higher levels of emotional sensitivity (ibid).
In their 1999 study, Pressman and colleagues found that maternal sensitivity was not correlated with children’s initial expressive language scores, but was positively correlated in their follow up assessments 12 months later [64][49]. In their regression analyses, maternal sensitivity positively predicted expressive language scores and accounted for 10% of the variance. In their 1998 study, they uncovered that maternal sensitivity had a larger positive effect on language in the sample of deaf children compared to their hearing sample [63][48].

2.3.3. Parental Communication Behaviours

In the study from Nicastri et al. [13][11], parents received nine whole-group sessions and three individual sessions of training over 10.5 months. The intervention was based on the ‘It Takes Two to Talk’ Hanen program [100][83] and involved video modelling, where parents had opportunities to put their training into practice at home. Strategies within the program included waiting and observing the child, following the child’s lead, interpreting the child’s behaviour, parallel talk, and expanding and recasting the child’s language. The authors reported significant gains in parent communication behaviours and parental sensitivity post-intervention and noted that parents in the treatment group had children with significantly better language skills, when formally assessed three years post treatment.

A pilot RCT [34][68] involved parents receiving weekly, hour-long sessions for six months, where they were explicitly taught to use strategies to promote early communication. The authors referred to methods such as enhanced milieu teaching [101][84], prelinguistic milieu teaching [102][85], and The Hanen Program It Takes Two to Talk [100][83]. Examples of strategies include sitting face to face, using gestures, imitating/mirroring the child’s actions, and turn taking. The study reported that parents in the treatment group increased their use of communication support strategies by 17% compared to 2% in the control group., There was a large effect size of 1.09 (p = 0.03) for the difference in gains in deaf children’s prelinguistic speech skills between the treatment and control groups.

3. Summary

The four main areas of PCI uncovered have some parallels with the review on children with language difficulties by Roberts and Kaiser [30][86], where the three most measured parent strategies were: parent responsiveness, use of language models and rate of communication. Similarly, a review by Holzinger and colleagues [104][87] on children with cochlear implants uncovered family involvement and parental linguistic input as key themes in their results. Additionally, within PCI research in the hearing population, the same set of behaviours are commonly measured [35][88].

The most prominent way of assessing PCI was with coding systems to analyse interactions. However, coding methods differed depending on the authors’ research focus. Some of the coding systems referred to well-known frameworks such as those from Waxman and Spencer [44][29], where attention-getting behaviours are well described and the coding scheme from Adamson, Bakeman, and Deckner [93][79], which includes 11 states of joint engagement. Other coding systems were created for the purposes of the particular study and papers did not report on the piloting of coding prior to their use. Behavioural observation is the ideal method for assessing the quality of interactions and reduces the risk of bias that may arise from the use of self-reporting tools [107][89]. Lotzin et al. [35][88] also limited their review of PCI assessments to objective instruments, with all 24 of their included measures being validated rating scales. Longer periods of joint engagement, increased parental sensitivity and a range of facilitative language techniques were all correlated with higher levels of language in deaf children. Parents with higher rates of maternal sensitivity and language stimulation have a greater effect on their child’s expressive language scores over time [13,64][11][49]. An important correlation highlighted by Vohr et al. [66][51] was that parents with more support and higher SES had decreased intrusiveness, directiveness and negative regard. The better supported a parent is, the more sensitive, responsive, and positive they will be in their interactions. Hintermair [109][90] mirrored this finding in his study with parents of deaf children showing that child development profits from parents accessing ‘personal and social resources’ that influence their coping process and significantly lower stress. Furthermore, Zaidman-Zait et al. [110][91] found that higher levels of child acceptance were associated with lower levels of parenting stress in parents of deaf children.

34. Recommendations

We make the following recommendations for future research on PCI and deafness:
1.
Provide full details with regard to participant information, for both the child and their parents including level of deafness, amplification use, child communication profile and parent-to-child communication profile (see ‘Language Access Profiles’ from Hall [113][92]).
2.
Report all methodological details of parent–child interaction assessment including who filmed the PCI, location of the assessment, instructions given to parents, length of the recording and length of film analysed.
3.
Use validated scales to assess PCI. We refer readers to Lotzin et al. [35][88] for their comprehensive list of psychometrically tested measures, where Biringen’s Emotional Availability Scales [96][82] are listed. This was the most commonly used validated scale in this review. In addition, reliability statistics should be reported.
4.
Use frame-by-frame coding as a detailed method of analysis. Coding schemes should be explained in detail and their development and pilot testing described. Reliability statistics should be reported.
5.
Recruit more representative samples of families with diverse socio-economic status and ethnicity.
6.
Recruit and/or include deaf children with additional needs for similar reasons. The proportion of deaf children with additional needs is 22% [114][93].
7.
Carry out more RCTs to explore causation between parental interaction and deaf children’s language growth.

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