Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy


Health and Rehabilitation Sciences


Oram Cardy, Janis

2nd Supervisor

Bagatto, Marlene P



Early Hearing Detection and Intervention programs are associated with improved spoken language outcomes for children who are deaf/hard-of-hearing. Best practice recommendations call for regular spoken language outcome monitoring to support decision making for all stakeholders (families, audiologists, speech-language pathologists, and program managers).

Despite the clear calls for spoken language outcome monitoring, there is no peer-reviewed guidance as to how Early Hearing Detection and Intervention programs can best accomplish this monitoring. This dissertation evaluates the assumptions underlying spoken language outcome monitoring and contributes a new procedure developed for a Canadian Early Hearing Detection and Intervention program: the Ontario Infant Hearing Program.

Whether decisions can be validly made using assessment data underpins the tenability of spoken language outcome monitoring. Chapter 2 considers test misuse across the profession of speech-language pathology from test design to clinical practice. I argue that a conceptual validity framework is one potential solution. This framework is applied throughout the dissertation.

Chapter 3 aims to develop a spoken language outcome monitoring procedure to support the Ontario Infant Hearing Program. This chapter describes the process I engaged in, including a scoping review and critical appraisal of norm-referenced spoken language tests, to develop an outcome monitoring procedure for the Infant Hearing Program.

Prior to implementing the recommended procedures province-wide, the Infant Hearing Program needed evidence as to whether the recommendations (a) meaningfully inform stakeholder decisions and (b) are feasible to implement. Chapter 4 reports on a pilot implementation of the recommended procedures and speech-language pathologists’ perceptions of it.

During development of the procedure outlined in Chapter 3, one of the key vulnerabilities I recommended to monitor was early vocal development in children who are younger than 2 years. Chapter 5 is a survey study capturing the clinical questions speech-language pathologists’ have about early vocal development of children who are deaf/hard-of-hearing to inform future projects to assess the validity of candidate vocal development assessments.

Overall, this dissertation contributes a spoken language outcome monitoring procedure for Early Hearing Detection and Intervention programs and highlights the tension between decisions, psychometrics, and implementation, in accomplishing spoken language outcome monitoring to inform best practice recommendations.

Summary for Lay Audience

Early Hearing Detection and Intervention programs are designed to help children who are deaf/hard-of-hearing access language (spoken or signed) early in development so that they do not have difficulty learning language when they are older. For children who are learning spoken languages, best practice recommendations say that these programs should regularly measure language development so that they know that services are effective, and children are on track for learning spoken language. However, there is currently no research that describes how programs should measure spoken language, whether the tools that speech-language pathologists need exist, and whether the tools are easily used in practice.

This dissertation aimed to identify whether it is currently possible to measure spoken language development in children with hearing loss and design a method to measure spoken language development for a Canadian Early Hearing Detection and Intervention program. This dissertation explores how stakeholders (i.e., speech-language pathologists and government managers) use tests to make decisions and applies this framework to the development of a new spoken language outcome monitoring procedure. Then, this dissertation evaluates whether the new procedure results in data that are usable for program evaluation and suitable to implement in clinical practice. Finally, this dissertation documents the questions that speech-language pathologists have about children who are deaf/hard-of-hearing’s vocal development to inform the design of new approaches to incorporate into the outcome monitoring procedure.