Northland Community and Technical College

Occupational Therapy Assistant Program

Critically Appraised Topics Assignment
BAILLY SAGER
Focused Question:
What can occupational therapy do, specifically in the classroom, to help someone who is deaf
communicate better with the hearing world?
Clinical Scenario:
It has become apparent in recent findings that deaf adolescents are not learning the proper
social and communication skills to successfully participate in the hearing world. Many
individuals who are deaf express a desire to have social relationships, but describe themselves as
being lonely and depressed because they have established few close peer relationships (Most,
2007). As retrieved by (Lu, 2014), these individuals have not developed proper language skills
so in return, that makes it difficult to communicate with their peers and is frustrating. Almost one
in every five deaf and hard of hearing students in the public schools is the only such student in
their school, so it is understandable how a deaf adolescent may be feeling isolated or depressed.
It has been observed in the Fargo Public Schools community the daily battles a deaf student has
gone through. That includes a lunch period sitting with peers but not interacting with anyone,
writing on a piece of paper to communicate with fellow students and teachers, and the use of an
interpreter to understand what is being said in the classroom (personal communication, 2011).
Although there are deaf schools across the country, it is important for a developing deaf
student to be exposed to the hearing world, to learn how to communicate with anyone so they
may hold a job, or simply order at a restaurant. With that being said, it is also important that the
public schools who have deaf and hard of hearing students teach ASL because it is the main form
of communication that the deaf culture uses. Although various schools and programs teach this
language, it is not an easy language to learn. This makes learning ASL a difficult task, unless
there is motivation behind it. The general perception of hearing people is that all deaf people are
disabled, when in fact that is not true and it is sometimes considered offensive to those who are
deaf. Mutual respect for one another is very important in learning this language successfully
(Kemp, 1998).
Two to three out of every 1,000 children in the United States are born with a detectable
level of hearing loss in one or both ears (Quick Statistics 2014). One would think that with that
amount of children with hearing loss, there would be more resources widely available to
accommodate them with adaptive equipment and classes. Our society relies a lot on technology
in this day and age. Texting and other message forms have made it easy, but what about when
someone needs to order food or sit down for an interview? The deaf community is unable to
communicate effectively with the hearing world because we are either unaccepting of it or
unwilling to accommodate those who need it.

Summary of Key Findings:

Level II:
Peer Victimization Experienced by Children and Adolescents Who Are Deaf or Hard of
Hearing; Kouwenberg, M., Rieffe, C., Theunissen, S., De Rooij, M. (2012)
This article talks about victimization in children, specifically those who are deaf or hard of
hearing. Victimization in deaf or hard of hearing students may be greater than hearing students. A
total of 188 children and adolescents from the Netherlands and the Dutch speaking part of
Belgium were included in the study; 94 were deaf and hard of hearing and 94 were hearing. The
hearing group was the control group who were randomly picked from primary and secondary
mainstream schools. Each participant was tested individually either at home or school in two
sessions that lasted from 30 minutes to an hour. They used a questionnaire that looked at
victimization, parental sensitivity, parents expectations, and childrens level of sadness and
anger. The hearing students viewed each question on a laptop and answered using the three
available responses. The deaf and hard of hearing students watched a video clip and used an
interpreter to answer. The results showed that deaf and hard of hearing children in special
education reported victimization more often than deaf and hard of hearing children in regular
education. Deaf and hard of hearing children reported fewer invitations to parties, received more
mean comments, and being more often ignored than hearing children. The results stated that
parents play a large role in reducing social experiences by deaf and hard of hearing children and
adolescents.
Level III:
Peer Attachment and Loneliness Among Adolescents Who Are Deaf: The Moderating
Effect of Personality; Lu, A., Yu, Y., Hong, X., Feng, Y., and Tian, H. (2014)
This article looked at the effects of peer attachment on loneliness among a group of adolescents
who were deaf. There were 98 deaf participants from 5 different schools in grades 5th to 10th in
Guangdong province of China, ages 10 to 22. They completed anonymous questionnaires about
peer attachment, personality, and loneliness. The peer attachment questionnaire had 25 items to
look at: trust, communication, and alienation and it was rated on a 5 point scale. The second set
of questions had 74 items looking at neuroticism, extraversion, psychoticism, and lie. The last set
of questions had 24 items, which looked at loneliness and social dissatisfaction at school. They
found that peer attachment, extraversion, and loneliness correlated to each other. The results
showed that peer attachment predicted loneliness more with highly extraverted adolescents than
for the introverted ones. The data was studied and it proved that the mental state varied across
the border depending on the level of extraversion. When comparing adolescents who have
normal hearing, deaf adolescents have more difficulties to overcome in developing interpersonal
communication skills and sustaining relationships. They stated that social skills training with

peers would be a breakthrough point to provide interventions for adolescents who are deaf and
who are experiencing great loneliness.
Acceptance of Deaf Students By Hearing Students in Regular Classrooms; Cambra, C.
(2002).
This article looked at 792 hearing students ages 10-20 years old in 22 different schools in Spain.
They were asked 19 questions about deaf students being in the same schools as hearing students.
There were 34 deaf students ages 12-19 years old who were evaluated. It was on a 5 point scale,
1 being I completely agree and 5 being I completely disagree. At every school, there was a
speech therapist that made sure all of their education needs were met. Once the questionnaire
was completed, it was collected and analyzed. One of the questions said, A deaf student could
not become one of my best friends. The average score for that was 4.48, meaning they strongly
disagreed with that statement. The results showed that hearing students felt that students with
deafness-related disabilities could benefit better in a special school. It also showed that hearing
students did not consider their deaf peers to be as hard working as themselves. The results
showed that although the younger students show that they favored relationships with deaf
students, they indicated that communication wasnt always easy. The majority of hearing
students felt that deaf students may benefit more in a special school and did not work as hard as
hearing students.
Deaf And Hard Of Hearing Children And Adolescents In China: Their Fears And
Anxieties; Li, H. and Prevatt, F. (2010).
This study examined the fears and anxieties of deaf and hard of hearing students in Hebei
Province in northern China. A total of 61 students in a special residential school for deaf and hard
of hearing children and adolescent were used. A total of 64 hearing students also participated in
this study. All were either middle or high school level. It took into consideration the teacher and
parents report on the children. The first questionnaire had 80 items on a 5 point scale, and it is
used to indicate the level of fear for each item- fear of criticism, unknown, or failure. The second
part had 37 items and they answered yes or no to anxiety related questions. The deaf adolescents
and children showed that they showed overall high fear levels and concentration anxiety than
hearing students. The study looked at specific fears, total fears and anxieties of students.
Regardless of status, females showed more total fears than males, while the males showed more
total anxieties.

Level V:

Deafness And Hearing Loss-A Global Health Problem; Sneed, S. and Joss, D. (1999).
This paper looks at how deafness and hearing loss has been misunderstood throughout history, as
well as the education of deaf children with appropriate communication. This has been a common
topic of discussion throughout the years. According to the article, a congenitally deaf child will
have a much more difficult time adapting to his normal society and family than a child who
experienced a hearing loss after the onset of speech. If a child is born without the knowledge of
sound and spoken language, he may experience a delay in development from a lack of stimuli if
there isnt another form of communication presented to him right away. Individual factors such
as intelligence, motivation, personality, and sense of humor also play a major role in living
successfully with deafness. Because about 90% of deaf children have hearing parents, it usually
is an emotional time for the parents and they may even go through mourning as they do not
know how to raise a deaf child. The family plays a major role in any childs life, but especially
for a deaf child because he/she is unable to communicate their needs right away. The school is an
environment where children develop social skills, appropriate communication skills, group
participation, coping skills, understanding and interpreting of values, and learning how to learn
on ones own. The article states that an occupational therapist would be a good resource for a
deaf child experiencing problems with those skills. Most societies will either accept deafness as a
separate and unique identity or reject it completely. Deafness is an important issue that needs to
be addressed because if affects everyone that a deaf person comes into contact with.
Health Information Needs of Deaf Adolescent Females: A Call to Action; Smith, C.,
Masssey-Stokes, M., Lieberth, A. (2012).
This article compares deaf and hearing adolescent females and whether each group is getting
health risk information. Deaf youth tend to have insufficient knowledge about important issues
such as: the effects of tobacco, human sexuality, HIV/AIDs, and mental health issues. This is
because relaying that information through school, peers, or parents may present as difficult. Deaf
youth tend to visit their doctors less than hearing youth because they do not have a sufficient way
of communicating without a parent or hiring an interpreter. Obtaining the skill and signed
vocabulary needed to discuss important health topics such as puberty, human sexuality, tobacco,
alcohol and other drugs is another challenge. Because of this, barriers form which can cause a
disconnect and isolate the child from the parents. The authors state that there needs to be a tool to
provide deaf teen girls with access to reliable, accurate, health information that has both captions
and presented visually in American Sign Language.
Why Is Learning American Sign Language A Challenge? Kemp, M. (1998).
This article talks about how American Sign Language is growing in population, but it is not as
easy of a language to learn as people perceive. The author goes into detail about how ASL is a
complex language and it requires extensive practice and exposure just like any other language.

He compares ASL to other languages, such as French, Hungarian, and Vietnamese. He splits
numerous languages up into four separate categories based on their level of difficulty learning.
He analyzes the required length of training and speaking proficiency level. He states that ASL
would fit into category 4, as it requires full English language knowledge in order to learn. If a
person is not fully knowledgeable in their first language, odds are they will not be successful
with ASL. The author goes on to say that those who are motivated will seek out opportunities to
interact with deaf people and will therefore maintain high levels of signing. He is basically
saying that although it may be difficult to learn, the more you practice and interact, they will be
motivated to maintain and improve their ability to sign.
A New Dedicated Mental Health Service For Deaf Children And Adolescents; Wright,
Walker, Holwell, Gentili, Barker, Rhys-Jones, Leach, Hindley, Gascon-Ramos, Moore
(2012).
This article goes into detail about the National Deaf Child and Adolescent Mental Health Service
that was started in England. It used quantitative and qualitative research to evaluate, assess and
intervene for severe to profoundly deaf children and young people with serious child mental
health problems. They used teleconferencing, texting, and webcam in clinics, home and school
visits. In England and Scotland, approximately 1 in 1,000 children are born with a permanent
degree of deafness. Research has consistently shown that the prevalence of emotional and
behavioral problems is higher in deaf children than hearing children (Hindley, 1997). The first
targeted mental health services for deaf adults was established in 1963, but were not dedicated to
deaf children and adults. Most deaf children have hearing parents (Ross, 2004) who are usually
unprepared for the arrival of a deaf child and many struggle to meet their developmental needs in
the first few years of life (Koester, 1998. Harris, 2001). A national service for deaf children and
adolescents with mental health problems was established in 1999 which consisted of deaf and
hearing professionals. There are 4 main centers now located in York, London, Dudley, and
Taunton, with an age range of 8-18 year olds. It offers teachers, teaching assistants, and
appropriate interpreters based on the childs language. This new service shows that the
government is on board to make services for deaf children and young people access to services in
need. The article also states that there needs to be a high quality public health system,
communication and education policies in place in order to give each child the support and
intervention that they need.

Bottom Line for Occupational Therapy Practice:

Occupational Therapys Role:

Providing education to all involved in the students life about peer interactions, health
concerns
Working on appropriate communication and social skills
Providing fun activities that will encourage interaction between deaf and hearing students
Being a part of sign language classes-making it fun and encouraging
Role playing/scenarios for the specific individual
Encouraging group participation by collaborating with the student on ideas
Helping the student understand and interpret values within the classroom
Helping the deaf student come up with solutions when encountering problems in school

After reviewing the eight articles, it is apparent that deaf adolescent and children struggle
with fitting in with their peers due to lack of communication, introversion, fears, and anxieties
(Aitao, 2014). Occupational therapy professionals would be able to assist in coming into the
schools and working on appropriate communication skills, socialization skills, group
participation understanding and interpreting values, learning how to work on ones own, and
adapting to high anxiety situations for the deaf student. After high school they will not be
surrounded by interpreters and other deaf people constantly to make communication easier so it
is essential these children have the appropriate skills. Because most societies will either accept
deafness as a separate and unique identity or completely reject it, it is hard to predict what will
happen in a classroom with hearing students (Sneed, 1999).
According to (Wright, 2012), most deaf children have hearing parents (Ross, 2004) who
are usually unprepared for the arrival of a deaf child and many struggle to meet their
developmental needs in the first few years of life (Koester, 1998, Harris, 2001). Educating
everyone who is involved in the childs life would be needed in order for him or her to reach
their full potential. That includes: parents, teachers, family members, therapists, paras, friends,
and fellow students. Occupational therapy professionals would also want to get the parents
involved as much as possible because in order for the child to use the skills taught at school, they
need to be able to practice that at home as well. Occupational therapy practitioners would be able
to collaborate with teachers and interpreters to develop a plan on infusing sign language in the
everyday class. Not only would this benefit the deaf student, but it would be teaching the
hearing students a second language. Starting with basic signs, such as the alphabet, numbers,
colors, animals, then slowly working up to more difficult signs (Kemp, 1998). This would be
getting the deaf student involved in teaching, and they also would be able to interact with their
peers more. When comparing adolescents who have normal hearing, deaf adolescents have more
difficulties overcoming and developing interpersonal communication skills and sustaining
relationships (Li, 2010). It was stated that social skills training with peers would be a
breakthrough point to provide interventions for adolescents who are deaf and who are
experiencing great loneliness. Kids are naturally very curious and would have a lot of questions
to ask. The more they know, the more they will understand why a deaf student needs to have an
adult (interpreter) with her to interpret teachers directions or why they go to another room to do
assignments or tests. Although learning the language is seen as difficult, OTs can make learning

it fun. There are tons of videos and audios to learn from. For example, there is a video that shows
basic colors and animals and has a song to go with it (captains are on screen), while also signing
so everyone can enjoy. There are also a lot of apps on the internet that are used for
communication. A hearing person would be able to type what they wanted to say on an iPad, and
on the other side of the iPad, there would be a person on the screen signing what they just said.
Because this would be a fun way to communicate, it would encourage interaction and instant
signing. This would be great to get the kids interactive with the hearing students. This would
work on social skills and ease anxiety and fears of the deaf and hard of hearing (Cambra, 2002).
It is important to address the fact that some deaf students who are in special education
feel victimized by their peers in regular education classes because they are different than them
(Kouwenberg, 2012). This is because the hearing students view the deaf students as different
from them and the unknown can be intimidating. Kids are naturally very curious and would have
a lot of questions to ask. The more they know, the more they will understand why a deaf student
needs to have an adult (interpreter) with her to interpret teachers directions or why they go to
another room to do assignments or tests. Although learning the language is seen as difficult, OTs
can make learning it fun. There are tons of videos and audios to learn from. For example, there is
a video that shows basic colors and animals and has a song to go with it (captains are on screen),
while also signing so everyone can enjoy. There are also a lot of apps on the internet that are
used for communication. A hearing person would be able to type what they wanted to say on an
iPad, and on the other side of the iPad, there would be a person on the screen signing what they
just said. Because this would be a fun way to communicate, it would encourage interaction and
instant signing. This would be great to get the kids interactive with the hearing students. This
would work on social skills and ease anxiety and fears of the deaf and hard of hearing (Cambra,
2002). Another example would be: an occupational therapist would work with a deaf student on
preparing to invite other students to a party. This could work on their writing skills,
communication skills. They will have to go up to each child and effectively communicate with
them so that they know when, where, and what it is for. The party would give the kids a chance
to get to know each other outside of school and get the parents involved as well. Open
communication with them would encourage play outside of school.
Another issue that was brought up was educating deaf adolescents on health risks and
information. It has been seen that there is not a whole lot out there for deaf teens to find accurate
information (Smith, 2012). Deaf youth tend to have insufficient knowledge about important
issues such as: the effects of tobacco, human sexuality, HIV/AIDs, drug and alcohol abuse, and
mental health issues. The article proposed that there should be a tool developed for them to
understand clearly. They recommended visual aids, captions, and an interpreter readily available.
An occupational therapist would be able to come in and help find that information and present it
to the patient along with an interpreter to help clarify questions. The therapist would also be able
to work on them on effective and appropriate ways to approach their doctor or parents. Making a
list of concerns, questions or comments and role playing how to approach the situation would be
a few examples of what they would work on. With this knowledge, a deaf patient would be able

to feel more comfortable and hopefully communicate with their doctor and parents about
concerns and questions about their health.
Review Process:
Inclusion Criteria:
Deaf adolescents
American sign language
Deaf students
OT and deaf adolescents
Exclusion Criteria:
Deaf Geriatrics
Blind and Deaf
Search Strategy:
Categories
Patient/Client Population
Intervention
Comparison
Outcome

Key Search Terms

Patients with hearing loss/deafness
Occupational Therapy
At home, with interpreter, in schools
To improve the communication between a deaf
client and the hearing world. (at a job, store, movie
theater)

Databases and Sites Searched:

Databases: All EBSCOhost databases were searched.
Sites: National Institute on Deafness and Other Communication Disorders (NIDCD)
www.nidcd.nih.gov
Quality Control/Peer Review Process:
The focus question was determined after using the PICO worksheet method. The eight peerreviewed articles were searched and located by the NCTC Library under EBSCOhost. A total of
eight peer-reviewed articles and one website were used to answer the focus question. After the
document was completed it was peer-reviewed twice by fellow colleagues who also are in the
Occupational Therapy Assistant (OTA) classes at Northland Community and Technical College
and by the EFP instructor of the OTA program.

Results of Search:

Summary of Study Designs of Articles Selected for Appraisal:

Level of Evidence Study Design/Methodology of Selected
Number of Articles Selected
Articles
Level I
Systematic reviews, meta-analysis,
0
randomized controlled trials
Level II
Two groups, nonrandomized studies (e.g.,
1
cohort, case-control)
Level III
One group, nonrandomized (e.g., before
3
and after, pretest, and posttest)
Level IV
Descriptive studies that include analysis
0
of outcomes (single subject design, case
series)
Level V
Case reports and expert opinion, which
4
include narrative literature reviews and
consensus statements
Qualitative
0
Limitations of the Studies Appraised:
Level II:
1. Peer Victimization Experienced by Children and Adolescents Who Are Deaf or Hard of
Hearing
Study done in Belgium and Netherlands
o Their viewpoints may not be the same as what is view in the United States:
o Deaf culture may not be the same as the United States
Different school system compared to the U.S.
Different parenting styles-how one parent parents could be considered
wrong/different to another parent.

Small sample size was small (188 participants)

o A larger sample would have been beneficial in collecting more accurate
information.
Level III:
1. Peer Attachment and Loneliness Among Adolescents Who Are Deaf: The Moderating Effect of
Personality
The study done was on a small sample size (98 participants)
o A larger sample would have yielded more accurate results
Done in a foreign country-China
o Deaf culture may not be the same as the United States
o The views on certain areas might not be the same as U.S. researchers
Results may not be totally accurateo Done in school, may have lied, bias, may not feel comfortable answering
Questionnaire was not very long
o There could have been more questions to clarify certain results

2. Acceptance of Deaf Students By Hearing Students in Regular Classrooms

Study conducted in Spain
o The views on certain areas might not be the same as U.S. researchers
o Deaf culture may not be the same as the United States
Not a lot of information on the deaf students
o Questionnaire was for hearing students about the deaf students
Not randomized
o If it would have been randomized, the results would have been considered more
accurate
Small sample size
o The views on certain areas might not be the same as U.S. researchers
o Deaf culture may not be the same as the United States

3. Deaf And Hard Of Hearing Children And Adolescents In China: Their Fears And Anxieties
Students in China, not the U.S.
o Educational system is different here in the U.S. compared to China
o Deaf students may be treated differently there
Not randomized-students specifically picked
o This does not show as accurate of results as it could be
Level V:
1. Deafness And Hearing Loss-A Global Health Problem
Expert opinion
o A lower level of evidence indicates less reliable information-bias, not objective
Did not go into detail about occupational therapy
o Did not say what occupational therapy could do, which would have been
beneficial to the research question
From 1999
o This could mean it may be outdated/going out of date soon.
2. Health Information Needs of Deaf Adolescent Females: A Call to Action
Expert opinion
o A lower level of evidence indicates less reliable information-bias, not objective
Limits to only females
o Males and females can both be deaf, and it did not mention any health risks that a
deaf male may need to be aware of
No study, but stated multiple studies within
o Because no study was done, there was not a whole lot of new information that
was being used to back up the issue
3. Why Is Learning American Sign Language A Challenge?
It was an expert opinion-one persons opinion on the subject

o Bias
o May not be completely objective information
From 1998
o It may be outdated information
4. A New Dedicated Mental Health Service For Deaf Children And Adolescents
Out of the country
o May not have the same needs as what the U.S. has
Talked about deafness and mental illnesses
o Not everyone who is deaf has a mental illness and the research question does not
mention mental illness
Did not state treatment
o Knowing what type of treatment used would have been beneficial

Articles Selected for Appraisal:

Aitao, L., Yanping, Y., Xiuxiu, H., Yi, F., Haiping, T., & Jianhua, L. (2014). Peer Attachment
And Loneliness Among Adolescents Who Are Deaf: The Moderating Effect Of
Personality. Social Behavior & Personality: An International Journal, 42(4), 551-560.
doi:10.2224/sbp.2014.42.4.551
Cambra, C. (2002). Acceptance of deaf students by hearing students in regular classrooms.
American Annals Of The Deaf, 147(1), 38-45
Kemp, M. (1998). Why is learning American Sign Language a challenge?. American Annals Of
The Deaf, 143(3), 255-259
Kouwenberg, M., Rieffe, C., Theunissen, S. M., & de Rooij, M. (2012). Peer Victimization
Experienced by Children and Adolescents Who Are Deaf or Hard of Hearing. Plos
ONE, 7(12), 1-10. doi:10.1371/journal.pone.0052174
Li, H., & Prevatt, F. (2010). Deaf And Hard Of Hearing Children And Adolescents In China:
Their Fears And Anxieties. American Annals Of The Deaf, 155(4), 458-466.
Sneed, S., & Joss, D. (1999). Global health issues. Deafness and hearing loss -- a global health
problem. Work, 12(1), 93-101.
Smith, C. E., Massey-Stokes, M., & Lieberth, A. (2012). Health Information Needs of d/Deaf
Adolescent Females: A Call to Action. American Annals Of The Deaf,157(1), 41-47.
Wright, B., Walker, R., Holwell, A., Gentili, N., Barker, M., Rhys-Jones, S., & Moore, K. (2012).
A new dedicated mental health service for deaf children and adolescents. Advances In
Mental Health, 11(1), 95-105.

Other Resources Found:

Quick Statistics. (2014, October 3). Retrieved October 11, 2014, from
http://www.nidcd.nih.gov/health/statistics/pages/quick.aspx
Fargo Public Schools. Personal Comunication. 2011.
Bailly Sager/OTAS
February 5th, 2015