A baby fails a newborn hearing screening and an auditory brainstem response (ABR) indicates profound bilateral hearing loss. From an audiologist’s perspective, fitting for hearing aids and an evaluation for cochlear implant candidacy are often the next steps. But for parents the lag time between identification and implantation is often a stressful time that involves waiting and worrying. This lag, during which infants do not have access to auditory linguistic input, occurs during a sensitive period of prelinguistic communication development (Ruben and Schwartz, 1999). What can pediatric audiologists and early intervention providers do during this critical period of development? The results of the first clinical trial (NCT01963468) of a pre-implantation communication treatment (PICT) allow us to answer this question. 

Persistent language delays following early implantation suggest a cochlear implant alone is insufficient for normal language skills post-implantation (Niparko et al, 2010). But waiting to initiate communication treatment until after the cochlear implant may be too late, given the critical period for language development (Ruben and Schwartz, 1999). 

Effective early communication intervention delivered prior to implantation may be necessary to reduce such delays. Because infants do not have access to sound during this period, they may require additional support to acquire prelinguistic communication and language skills (Ruben and Schwartz, 1999). 

Early in life, infants and parents engage in interactions that form the foundation for language learning. When an infant is born with a hearing loss, these interactions are altered in two primary ways. First, hearing loss limits the amount of access to spoken language. Second, given that 90 percent of children with hearing loss are born to hearing parents, a hearing status mismatch between the parent and the child may result in communication interaction difficulties. Hearing parents, limited by their own communicative experience which is different than that of their infant, may have difficulty tailoring interactions to meet their infant’s learning needs. For example, hearing parents may use fewer visual strategies (Waxman and Spencer, 1997) and may be more directive (Fagan et al, 2014). These increased directive behaviors may result in fewer infant-parent interactions (Gale and Schick, 2009). 

Despite this mismatch, several parent behaviors are related to language development in infants with hearing loss. Visual support strategies (e.g., using gestures, moving objects into the child’s line of sight) provide input such that the developing brain begins to form symbolic representations during this critical time, despite the absence of auditory information (Ruben and Schwartz, 1999). Tactile support strategies (e.g., tickling or caressing the child to initiate and maintain an interaction) are associated with longer periods of engagement between child and mother (Loots et al, 2005). Use of responsive support strategies (e.g., responding to child communication) is associated with spoken language skills in children with cochlear implants (Cruz et al, 2013). Furthermore, interactive strategies (e.g., following the child’s lead) are associated with expressive language growth in children with hearing loss (Pressman et al, 1999). 

While correlational research suggests these support strategies have a positive impact on language development in children with hearing loss and for children with other disabilities (Cruz et al, 2013), the PICT trial is the first study to teach parents specific communication support strategies prior to implantation. PICT is implemented during a sensitive period between identification of hearing loss and implantation (Ruben and Schwartz, 1999). It involves visual, tactile, responsive, and interactive communication support strategies that are associated with stronger language skills in children with hearing loss (Loots et al, 2005; Pressman et al, 1999), and includes systematic parent training which has been shown to be effective at increasing parents’ use of communication strategies in other populations of children (Roberts and Kaiser, 2015). 

Support Strategies

PICT includes three classes of communication support strategies. 


First, parents are taught to use visual strategies. Visual strategies are especially important for infants with profound hearing loss who do not have access to linguistic auditory information. The primary visual strategy is the use of gestures by parents because, “children enter language hands first" (p.741, Goldin-Meadow, 2007). All children, regardless of hearing level, use gestures to communicate before they are able to say words (Iverson and Goldin-Meadow, 2005). In fact, deaf children not exposed to spoken or visual language point at the same number of objects as hearing children (Feldman et al, 1978). These children use gestures to direct an adult’s attention and to communicate about something they find interesting. 

Gesture use has a positive effect on language learning because

  • Gestures may elicit a communicative response from parents.
  • The act of gesturing (regardless of parent response) may make it more likely that the infant will learn a word for the object to which they pointed. 

Given the strong relationship between gesture use and language development, modeling gestures during this critical prelinguistic period may facilitate post-implantation spoken language skills. Other visual strategies include sitting face to face with the child, waiting until the child looks before starting an interaction, moving objects in the focus of the child’s visual attention, and using exaggerated facial expressions. Teaching parents to use visual strategies may be particularly important for hearing parents of children with hearing loss given they are less likely to use visual strategies than deaf parents. 

Interactive and Tactile

Second, parents are taught to use interactive and tactile strategies. Interactive strategies support increased engagement with a communication partner or activity. This increased engagement is especially important because it’s positively related to language learning (Adamson et al, 2004). Parents are taught to increase engagement by following their infant’s lead in play, choosing interesting and engaging toys, imitating the infant’s non-verbal actions, touching the child to attract or keep attention, and using tickling or physical touch to sustain engagement. These strategies are effective at increasing child engagement and subsequent language skills (Roberts and Kaiser, 2015). Teaching parents to use effective interactive strategies is essential for parents of children with hearing loss because mothers of infants showing signs of communication difficulties interact less with their infants (Alston and St James-Roberts, 2005).


Lastly, parents learn responsive strategies, such as responding to all child vocalizations and gestures and balancing turns by responding to each child utterance with only one comment. Maternal responsiveness at the time of cochlear implantation positively predicts language skills four years after implantation (Quittner et al, 2013). Most striking is the fact that maternal responsiveness and age of implantation were equally related to long-term language outcomes in children with cochlear implants (Niparko et al, 2010; Quittner et al, 2013). 

Responding to prelinguistic communication such as vocalizations and gestures is particularly important for infants with hearing loss. Because infants with hearing loss don’t receive auditory feedback to help shape their vocalizations, parent responsiveness is critical. Responding contingently to every communicative act teaches infants how to participate in social interactions. Once children have access to auditory information, language may be mapped to these vocalizations and gestures. As such, the goal of this prelinguistic period prior to implantation is to increase prelinguistic behavior and to teach infants the basic back and forth components of social interactions. 

Coaching Sessions

Parents are taught these strategies during one-on-one coaching sessions in three phases (visual, interactive and tactile, and responsive). At the beginning of each phase, the topic is introduced through an hour-long workshop in which the therapist: (a) defines the strategy, (b) provides a rationale for each component of the strategy, (c) describes how to do the strategy, (d) shows video examples of the strategy, and (e) answers parent questions about the strategy. Following each workshop, parents practice the specific set of strategies during sessions. 

Each session includes four segments: (1) the therapist reviews the intervention strategies taught in the workshop, (2) the therapist models the intervention strategy with the child, (3) the parent practices the strategy with her child with coaching from the therapist across four different routines and activities of the parent’s choice, and (4) the therapist provides feedback to the parent, summarizes the session, and answers the parent’s questions. 


The effects of parent use of these facilitative strategies on prelinguistic communication skills of infants with hearing loss was evaluated by randomly assigning 19 infants with hearing loss to either receive PICT or no treatment. Infants in both groups received their regular early intervention services. We measured children’s symbolic (following directions, use of objects) and speech skills (words, sounds) using the Communication and Symbolic Behavior Scales (CSBS,) after intervention. Parents in the PICT group used significantly more communication support strategies than parents in the control group. These differences in parent behavior resulted in changes in infant prelinguistic skills. After intervention, infants in the PICT group had greater speech and symbolic skills than infants in the control group. These results indicate that it is possible to improve prelinguistic communication even in the absence of auditory information. 

Now, rather than simply waiting for a cochlear implant, parents can feel empowered to teach their infant with hearing loss fundamental prelinguistic skills that do not depend on access to sound. First and foremost, we should teach parents to engage in meaningful, stimulating, and interactive exchanges with their infant. We should encourage parents to model gestures such that infants have a way to participate in social interactions. We should also teach parents how to recognize and respond to prelinguistic forms of communication such as gestures and vocalizations. Teaching parents the importance of their communicative behaviors prior to cochlear implantation is likely to have a cascading effect on spoken language skills in infants with hearing loss. These strategies result in increases of prelinguistic communicative behaviors (gestures and vocalizations), which serve as the foundation for spoken word learning providing a context in which parents can map new words.