Journal of Otology 17 (2022) 130e135

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Journal of Otology
journal homepage: www.journals.elsevier.com/journal-of-otology/

Impact of Auditory-Verbal Therapy on executive functions in children with

Cochlear Implants
Mohammad Ashori
Department of Psychology and Education of People with Special Needs, Faculty of Education and Psychology, University of Isfahan, Hezar Jarib Street, Azadi Square, Isfahan, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Auditory-Verbal Therapy (AVT) can be considered one of the best practices for children with
Received 21 February 2022 Cochlear Implants (CIs) who show impairments in cognitive skills such as executive functions. Hence,
Received in revised form this research examined the impact of AVT on the executive functions in children with CIs.
8 April 2022
Methods: This was a randomized case control study with pre- and post-intervention assessments. The
Accepted 12 April 2022
participants were 36 children with CIs and their mothers. They were randomly selected from rehabili-
tation centers and deaf pre-schools, and randomly allocated to a control (n ¼ 18) and a study (n ¼ 18)
Keywords:
group. The mean age of the children in the study and control groups was 3.11 ± 0.31 years and 3.20 ± 0.29
Auditory-verbal therapy
Early intervention
years, respectively. Participants in the study group received 20 sessions of AVT over 10 weeks at twice a
Executive functions week, while those in the control group did not. All mothers completed the Behavior Rating Inventory of
Executive Function Pre-school Version (BRIEF-P) before and after children in the study group completed
their AVT intervention. Data were analyzed by MANCOVA.
Results: The results suggest that AVT significantly influenced executive functions and all subscales
including shifting, inhibition, emotional control, working memory and organization/planning in children
with CIs.
Conclusions: These findings suggest that AVT may be effective in resulting in positive outcomes and may
play an important role in improving executive functions in children with CIs.
© 2022 PLA General Hospital Department of Otolaryngology Head and Neck Surgery. Production and
hosting by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction including a set of cognitive abilities. It consists of shifting, inhibi-

tion, emotional control, working memory and organization/plan-
The goal of education is, in general, equal opportunities in life ning (Gioia et al., 2003). Shifting can be described as moving freely
and full participation in society (Hendar and O'Neill, 2016). Deaf- from one activity or condition into another activity or situation
ness is a highly prevalent sensory impairment associated with (Nilsen et al., 2017). Inhibition refers to the capability to resist
changes in cognitive and metacognitive processes (Ashori, 2022; impulses and stop their behaviors at the appropriate time (De
Jayakody et al., 2018). This term applies not only to hereditary and Greeff et al., 2018). Emotional control refers to the effect of exec-
pre-lingual deafness, but also to acquired hearing impairment utive function problems on emotional expression and the child's
(Cardin, 2016). Given these definitions, educational placement for capability to control or adjust one's emotional responses (Beer
deaf students range from special sections to regular schools et al., 2014). Working memory can be described as the online
(Marschark and Knoors, 2012). Deafness, or even hearing loss, often representative memory, that is, the ability to hold information in
places a child in a problematic place (Ashori et al., 2019). Even mild memory for the aim of completing a task and coding data to obtain
hearing loss can lead to changes in neural flexibility and executive aims (Isquith et al., 2005). Organization/planning is defined as the
functions (Rudner et al., 2019). child's capability to manage current and future-oriented task re-
Executive functions are conceptualized as an umbrella term, quests (Hall et al., 2017).
Executive functions play a critical role in the lifetime perfor-
mance of children (Corte
s Pascual et al., 2019). These functions
E-mail address: m.ashori@edu.ui.ac.ir. appear in the early years of life. Indeed, behaviors representing
Peer review under responsibility of PLA General Hospital Department of working memory, shifting tasks and inhibitory control emerge
Otolaryngology Head and Neck Surgery.

https://doi.org/10.1016/j.joto.2022.04.002
1672-2930/© 2022 PLA General Hospital Department of Otolaryngology Head and Neck Surgery. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Ashori Journal of Otology 17 (2022) 130e135

before the age of two (Reznick et al., 2004). Executive functions Over the past two decades, improving executive functions in
facilitate the development of social, emotional, and cognitive skills children with hearing loss has been one of the most important
(Nilsen et al., 2017). Pre-school years may be one of the essential goals of intervention programs designed for this population (Maller
times in executive functions development (Sasser et al., 2015). Pre- and Braden, 2011). There have been few studies conducted on the
school children can retain more information for a longer time than effect of AVT on executive functions in children with CIs. According
infants. They have considerable skills in manipulating their mental to reports in the literature, it is better to use an AVT program to
information (Garon et al., 2008). For these reasons, we focused on improve executive functions in pre-school children with CIs.
the ages 2e4 years. Moreover, children at this age can change their Therefore, the current study was guided by the question: Is there a
attention from one task to another. They can combine the necessary significant difference in executive functions and subscales between
skills of executive functions and create more complex behaviors. AVT treated and non-AVT treated children?
Although executive functions have apparent implications for
early development, little research has been conducted on executive 2. Materials and methods
functions in pre-school children with CIs (Beer et al., 2014). Exec-
utive functions are higher-level cognitive skills that can be influ- 2.1. Participants
enced by hearing impairment (Peelle and Wingfield, 2016). The
best early implanted children may progress well in language and Thirty-six children with CIs aged 2e4 years and their mothers
literacy without specialized intervention, although educational participated in this study. The participants were selected from
interventions can be extremely helpful (Trussell et al., 2016). rehabilitation centers and deaf pre-schools by a simple random
Several rehabilitation approaches have been designed for people sampling method in Isfahan, Iran. They were randomly assigned to
with hearing loss (Kaipa and Danser, 2016). These approaches are a control (n ¼ 18) or a study (n ¼ 18) group. All of the children had
classified as: 1) Visual approach such as sign language; 2) Total worn one cochlear implant for longer than one year for bilateral
communication approach, which combines methods emphasizing profound hearing loss. The parents of the participants had normal
natural gestures, lip-reading, speech-reading, spoken language and hearing. The inclusion criteria were: onset of hearing impairment
signs; 3) Auditory-oral approach, which combines the use of re- before age six months, bilateral hearing impairment (aided
sidual hearing, speech-reading and speech; and 4) Auditory-verbal thresholds from 30 to 42 dB HL at 500, 1000 and 2000 Hz), using a
therapy (AVT) approach, which uses listening as the primary Med-El, Advanced Bionic or Cochlear brand CI, and Persian as the
method for language and speech development (Hallahan et al., first language at home and in school. Children were excluded from
2018). the study if they received educational services from other centers.
AVT is one of the best programs for improving speech, language, See Table 1 for demographic information. It should be noted that
and hearing development in children with hearing loss (Tejeda- children with CIs aged 2e4 years go to a rehabilitation center or
Franco et al., 2020). It is a family-oriented listening and spoken deaf pre-school in Iran. The children and their families had received
language program used for these children, initially coined by auditory training intervention before starting this study.
Pollack and Ling (Rosenzweig, 2017). In AVT, language, speech and As can be seen in Table 1, the mean age was 3.11 ± 0.31 years in
sound problems are addressed by focusing on cochlear reserve or the study group and 3.20 ± 0.29 years in the control group (t ¼ 0.63,
residual hearing (Brennan-Jones et al., 2014). AVT intervention p > 0.05). The mean hearing threshold before CI was 91.32 ± 1.90 dB
differs from other approaches, because in this intervention, the HL and 90.67 ± 2.04 dB HL for the two groups, respectively (t ¼ 1.13,
parent of the child must be present during all rehabilitation ses- p ¼ 0.08), while the mean CI-aided threshold was 27.19 ± 1.72 dB HL
sions (Estabrooks et al., 2020). Moreover, this program is planned and 26.54 ± 1.80 dB HL, respectively (t ¼ 1.09, p ¼ 0.09). The mean
based on the individual needs of children with hearing loss and the age at implantation was 9.72 ± 0.53 years in the study group and
expectations of their parents (Tejeda-Franco et al., 2020). 9.38 ± 0.66 in the control group (t ¼ 0.41, p > 0.05).
The main principles of AVT include hearing assessment and
early identification of hearing levels, familial education and sup- 2.2. The Behavior Rating Inventory of Executive Function Pre-school
port, suitable hearing amplification, listening to sounds and voices, Version (BRIEF-P)
continuous assessment of listening, speech, language and cognition
development, improving communication with individualized This inventory was proposed by Gioia et al. and includes 63
teaching and spoken language, and support of educational inte- questions (Gioia et al., 2003). The BRIEF-P has a teacher and a
gration and mainstreaming (Pollack, 1993). The AVT approach can parent version and is developed to evaluate executive functions in
help children with hearing loss in speech, cognition, executive children based on everyday behavior at home and in pre-school
functions and learning (Marschark and Knoors, 2012). It seems that setting. It is designed for pre-school children aged 2e6 years,
children with hearing loss have significantly more executive func- including children with traumatic brain injuries, learning disorders,
tion problems than normal-hearing children (Luckner and autism and attention disorders (Dzambo et al., 2018). The BRIEF-P
Movahedazarhouligh, 2019). For example, the results by Tejeda- includes five subscales: inhibition (16 questions), shifting (10
Franco et al. (2020) demonstrated that auditory rehabilitation questions), working memory (17 questions), emotional control (10
with the AVT approach improved speech parameters in children questions) and planning/organization (10 questions). Each ques-
with hearing loss. Chatterjee et al. (2019) found that AVT had sig- tion, is answered as Never, Sometimes or Often (scored from “1” to
nificant effects on the auditory skills, working memory, linguistic “3”). Low BRIEF scores indicate strong executive functions. The
processing, planning and organization in children with CIs. The BRIEF-P is a reliable and valid tool for measuring executive func-
finding by Hall et al. (2017) showed that children with hearing loss tions in pre-school children. Internal consistency by Cronbach's
experienced considerably more executive functions problems than alpha for this inventory ranges from 0.80 to 0.97 (Gioia et al., 2003).
their hearing peers. The findings by Kaipa and Danser (2016) For this study, we used the parent version with a Cronbach's alpha
indicated that AVT had significant effects on auditory perception, of 0.94 and test-retest correlation of r ¼ 0.79 to 0.84.
speech perception, receptive language, expressive language and
mainstreaming in children with hearing loss. The results by Beer 2.3. Procedure
et al. (2014) suggested that the executive functions in pre-school
children with CIs were lower than in their hearing peers. This study was approved by the Exceptional Education
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M. Ashori Journal of Otology 17 (2022) 130e135

Table 1
Demographic information of the children.

Variable Category Intervention group Control group t-test P

Sex Male 9 (50%) 10 (56%) e e

Female 9 (50%) 8 (44%) e e
Race/ethnicity Iranian/Persian 18 (100%) 18 (100%) e e
Age (years) 2e3 8 (44%) 8 (44%) e e
3e4 10 (56%) 10 (56%) e e
Mean age (years) M (SD) 3.11 (0.31) 3.20 (0.29) 0.63 0.17
Hearing thresholds (dB HL) M (SD) 91.32 (1.90) 90.67 (2.04) 1.13 0.08
CI-aided thresholds (dB HL) M (SD) 27.19 (1.72) 26.54 (1.80) 1.09 0.09
Age of implantation (months) M (SD) 9.72 (0.53) 9.38 (0.66) 0.41 0.11

M: Mean SD: Standard deviation.

Organization in Tehran, Iran (ID 97000-20223). Study goals were Session 17 included memory and hearing sequence, acoustic
explained to the managers of the rehabilitation centers and deaf highlighting, small function words, running speech, self-
pre-schools. Study procedures were explained to all mothers of the monitoring and short-term memory, whereas Session 18 included
participating children before signing a written informed consent. emphasizing, rewording, vocabulary, rephrasing, syntax, speech
The mothers were informed that participation in the study was modeling, perception-production loop and long-term memory. Yet
confidential and anonymous. Session 19 covered auditory memory span, pragmatic and social
The mothers were given instructions on how to complete the language, asking questions, self-advocacy skills, and working
BRIEF-P. They completed the BRIEF-P prior to intervention and memory.
returned it to the researchers before the participants were An example of a session content is as follows: At the beginning
randomly divided into the control and study groups. Children in the of the session, mothers of participants answered these questions:
study group participated in the 20-session AVT over 10 weeks at “How was the last week?” “Did your child hear or say anything
their rehabilitation centers or deaf pre-schools, and received sup- new?” We used Ling Six Sound Check for troubleshooting the
port from 2 AVT therapists. Children in the control group did not child's CI to ensure that children have optimal access to sound.
participate in this intervention. Two days after children in the study Most of the intervention session is spent on program aims. The
group completed the AVT intervention, all mothers of the children program was spelled in two different ways. Activities of the pro-
in both groups completed the BRIEF-P again as the post- gram might vary from child to child, although with the same target
intervention assessment. areas that included: 1) Audition: training by Erber's method
including auditory memory; 2) Speech: training on the production
2.4. AVT intervention and articulation of phonemes and syllables through listening; 3)
Language: training on syntax and receptive and expressive lan-
AVT was developed by Pollack and Ling in 1993 (Chatterjee et al., guage; 4) Communication: training on self-advocacy, asking ques-
2019; Tejeda-Franco et al., 2020). Although all AVT based programs tions, pragmatic and social language; 5) Cognition: training on
may adhere to all of the principles by the Bell Association for cognitive and academic skills. Aims of the session were discussed
Listening and Speaking Language, programs may differ in details with the mothers along with a debriefing on how the child did.
(Estabrooks et al., 2020). Table 2 gives an overview of the aims and Mothers were given time to ask questions before the session ended.
content of the 20 therapy sessions in this study. For example, Example pictures of the intervention group are shown in Fig. 1.

Table 2
Aims and content of AVT sessions.

No Aim Content

1 Audition, attending, recognizing, and Diagnostic therapy, auditory sense, awareness of environmental, and vocal sounds.
2 cognition Showing sound sources; use of visual, motor, and auditory clues; and Recall.
3 Identification of events and objects through their sounds, and respond to sounds.
4 Attending to distinct speech sounds or voices, auditory clues, and auditory memory.
5 Early vocalizing, speech, and cognition Reinforcement of vocalizations, active sounds, accurate repetition, and recognition.
6 Stimulation for vocalizations, word retelling, feedback loop, and ask what you heard.
7 Auditory skills and Memory Foreground-background, and recognizing from sound as the first information source.
8 Locating source of sounds in space, and stimulation of all attempts to discriminate.
9 Auditory closure, and discrimination and comprehension of sounds or voices.
10 Vocalizing with inflection, auditory, and Producing vowels, vocalization with different intensity, pitch, and duration.
11 speech skills Producing consonants, speech rate, segmenting words, and breathing speech.
12 Production and articulation of phonemes and syllable shapes through listening first.
13 Auditory, speech-language, and cognition Cognitive listening skills, locating sound sources at different levels and distances, phonetics, and memory span.
14 skills Phonological processes, morphology, stimulation of speech attempts, and auditory feedback.
15 Stimulation with meaningful words, auditory processing, and receptive language.
16 Hand cue, feedback loop, pause, prosody, rhythm, and tonally expressive language.
17 Auditory, speech-language, communication, Memory and hearing sequence, acoustic highlighting, small function word, running speech, self-monitoring, and short-
and cognition skills term memory.
18 Emphasizing, rewording, vocabulary, rephrasing, syntax, speech modeling, perception-production loop, and long-term
memory.
19 Auditory memory span, pragmatic and social language, asking questions, self-advocacy skills, and working memory.
20 Paying attention to the development of the whole child and cognitive/academic skills, shared reading of a book,
readiness to communicate, and formal education.

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M. Ashori Journal of Otology 17 (2022) 130e135

Fig. 1. Example pictures of the intervention group in an AVT session.

2.5. Data analysis Table 4

Results of ANCOVA for executive functions.

Descriptive indicators were analyzed. The normality of these Source SS df MS F Sig. Eta2 power
data was examined by the Shapiro-Wilk test. ANCOVA was run to Pre-intervention 181.19 1 181.19 17.01 0.001 0.31 0.92
determine the differences between the study and control groups on Group 603.37 1 603.37 56.65 0.001 0.62 0.97
executive functions, and to determine intervention effect. Differ- Error 351.68 33 10.65
ences between the two groups on executive functions subscales Total 1197.52 35
were determined using MANCOVA. SS: Sum of squares df: Degrees of freedom MS: Mean of squares.

3. Results
confirmed a good correlation between the variables (p ¼ 0.001),
and Levene's test indicated the homogeneity of the variances
Table 3 shows descriptive statistics of executive functions and
(p > 0.05). Therefore, the assumptions of MANCOVA were met. To
subscales before and after AVT intervention. It should be noted that
investigate the difference between groups in executive functions
mothers of children in the control group returned to the rehabili-
subscales, Roy's test was run (F ¼ 15.08, p ¼ 0.001), which
tation center at the same time as mothers of children in the study
demonstrated inter-group differences, as also shown by MANCOVA
group two days after children in the study group completed their
(Table 5).
AVT intervention, and completed the BRIEF-P for the second time,
Table 5 shows the group effect by AVT intervention, as evi-
which is also marked as “post-intervention”.
denced by post-intervention scores for inhibition (F ¼ 87.32,
In Table 4, pre-intervention scores were treated as the covariates
p < 0.001), shifting (F ¼ 76.25, p < 0.001), emotional control
of executive functions in both groups (F ¼ 17.01, p < 0.001). ANCOVA
(F ¼ 86.09, p < 0.001), working memory (F ¼ 91.17, p < 0.001) and
showed significant group effect by AVT intervention based on post-
planning/organization (F ¼ 97.98, p < 0.001). Based on Eta square
intervention executive functions scores (F ¼ 57.65, p < 0.001). Also,
test, it can be stated that a significant portion of the change in these
Eta square value indicated that 62% of the variation in executive
variables (62%, 58%, 61%, 63% and 64%, respectively) resulted from
functions was due to the intervention. In other words, the executive
the effects of AVT intervention. In other words, executive functions
functions score in the study group improved significantly with a
subscales score in the study group improved post-intervention
moderate effect size.
with a moderate effect size.
In determining the effects of AVT on subscales of executive
functions, Box's M test indicated the equality of multiple variance-
covariance (Box's M ¼ 0.68, p ¼ 0.37). Bartlett's test of sphericity 4. Discussion

The present study aimed to identify the impact of AVT on ex-

Table 3 ecutive functions in children with CIs. Findings suggest that AVT
Descriptive statistics of variables.
enhanced executive functions in the participants. These findings
Variables Test Intervention Control group were similar to those by Chatterjee et al. (2019), who reported that
group AVT improved auditory skill, short-term memory, working mem-
M SD M SD ory, linguistic processing, planning and organization in children
Inhibition Pre-intervention 33.92 2.64 33.23 2.27 with CIs. This study is also consistent with the study by Hall et al.
Post-intervention 26.11 2.05 31.08 2.14 (2017), which concluded that children with hearing loss experi-
Shifting Pre-intervention 22.88 2.59 22.00 2.73 ence significantly more executive functions problems than their
Post-intervention 16.38 2.10 21.92 2.13 same-age hearing peers. The finding of this study agrees with Beer
Emotional control Pre-intervention 23.34 1.99 23.08 1.72
Post-intervention 17.12 1.98 22.01 1.66
et al. (2014), who concluded that executive functions in pre-school
Working memory Pre-intervention 35.24 3.28 35.02 3.61 children with CIs are lower than those with typical hearing.
Post-intervention 26.16 3.05 33.13 3.44 From these studies, it can be concluded that executive functions
Planning/organization Pre-intervention 24.32 2.27 24.28 2.03 are an area where children with hearing loss often have difficulties
Post-intervention 17.19 2.15 23.05 2.01
(Ashori, 2022). It is thus vital to formulate appropriate programs for
Executive function Pre-intervention 139.70 7.14 137.61 7.28
Post-intervention 102.96 6.99 131.19 7.19 promoting executive functions in these children. Some programs
have been effective in enhancing executive functions in children
Shapiro-Wilks test confirmed data normality (p > 0.05). Homogeneity of regression
was also confirmed (F ¼ 1.37, p > 0.05). Levene test indicated variance homogeneity
with hearing loss. One program that helps these children is AVT
(F ¼ 0.29, p > 0.05). Therefore, the assumptions of ANCOVA were met. Results are (Estabrooks et al., 2020). The AVT approach includes individual
presented in Table 4. diagnostic sessions emphasizing the use of hearing in meaningful
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M. Ashori Journal of Otology 17 (2022) 130e135

Table 5
MANCOVA of executive function subscales.

Variables Source SS df MS F Sig. Eta2

Inhibition Pre-intervention 38.06 1 38.06 7.73 0.003 0.34

Group 430.24 1 430.24 87.32 0.001 0.62
Error 142.68 29 4.92
Total 691.38 35
Shifting Pre-intervention 34.07 1 34.07 7.08 0.004 0.31
Group 367.19 1 367.19 76.25 0.001 0.58
Error 139.49 29 4.81
Total 562.27 35
Emotional control Pre-intervention 18.16 1 18.16 5.05 0.009 0.29
Group 309.32 1 309.32 86.09 0.001 0.61
Error 104.11 29 3.59
Total 473.15 35
Working memory Pre-intervention 13.22 1 13.22 2.72 0.04 0.19
Group 446.06 1 446.06 91.17 0.001 0.63
Error 141.81 29 4.86
Total 602.87 35
Planning/organization Pre-intervention 24.00 1 24.00 6.97 0.002 0.31
Group 337.54 1 337.54 97.98 0.001 0.64
Error 99.76 29 3.44
Total 476.50 35

and optimal situations hence emphasizing on developing hearing CIs aged 2e4 years and their mothers. Audiologists and teachers
as an active sense (Ling, 1993). It emphasizes facilitating and pro- can use AVT to enhance executive functions in children with CIs.
moting the optimal acquisition of expressive language through They can do this during the pre-school years. The more monitoring,
listening (Chatterjee et al., 2019; Nandurkar and Susmitha, 2017). the better the results. Therefore, proper use of the AVT program has
The listening environment in AVT can be enhanced in various ways, been associated with desirable outcomes. It is recommended that
such as having the therapist sitting in front of a child and using audiologists use the AVT program for children with CIs. These
appropriate techniques including acoustic highlighting, pausing children can further develop their language skills and cognitive
and providing alternatives (Dornan et al., 2007). It is therefore abilities, and strengthen their executive functions. Finally, the same
possible that AVT may positively influence executive functions in program may improve executive functions for children with mild to
children with CIs. profound hearing impairment.
Hearing loss is associated with some problems in areas such as
communication, cognition and psychological wellness (Lederberg 5. Conclusion
et al., 2019). These issues can affect executive functions in chil-
dren (Nilsen et al., 2017). On the other hand, executive functions The growing number of people with CIs has led to an interest in
facilitate the development of cognitive, emotional, behavioral and the impact of AVT, specifically the utility of this approach. We know
social skills in deaf children (Ashori and Tajvar Rostami, 2020; Hall that children with CIs cope with many challenging issues, and often
et al., 2017). Deficits in executive functions are implicated in child they cannot find a suitable solution. AVT, through influencing lan-
psychopathologies (Hawkey et al., 2018). With early identification, guage skills, can lead to improved speech performance and cogni-
proper amplification and effective AVT with parents' participation, tive ability, and may play a beneficial role in enhancing executive
up to 80% of deaf children can be successful in regular education functions in children with CIs.
(Fobi and Oppong, 2019). Besides, appropriate use of AVT helps to
improve executive functions. Funding sources
In this regard, AVT may support children with CIs to become
more aware of their language skills and cognitive abilities. Given The authors disclosed receipt of the following financial support
that these children often face problems in speech and cognition, for the research, authorship, and/or publication of this article: This
they may benefit from a program that focuses on AVT to regulate research was registered by the Research Information Management
and manage their executive functions. Since AVT emphasizes System in Iran (ID 13768e170254) and was supported by the
attending, early vocalizing, recognition, feedbacks, sound locating, Exceptional Education Organization in Tehran, Iran (ID 97000-
memory, sound distance and levels, producing vowels and conso- 20223).
nants, speech discrimination and comprehension, short and long-
term memory and memory span, it may significantly affect exec- Declaration of competing interest
utive functions. AVT can therefore contribute to improvement of
executive functions in children with CIs. The author declared no potential conflicts of interest with
There were several limitations to this study. Although parents respect to the research, authorship, and/or publication of this
were part of both the study and control groups, they were not article.
necessarily matched otherwise. The sample size was small, and
only the parent version of the BRIEF-P was used in this study. The Acknowledgements
intervention program was conducted in 20 sessions and it was not
possible to have a follow-up visit. Executive functions in children We would like to thank all of the participants for their partici-
with deaf parents seem to be different from children with normal pation in this research.
hearing parents. Therefore, findings should be generalized with
precaution. References
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