The Role of Sign Language in Service Delivery for Individuals who are deaf or hard of Hearing: Knowledge, Attitudes, and Practices of Audiologists and Speech Language Pathologists
Abstract
Background and aims: Many parents rely on professionals for information to decide their children’s initial communication mode. Although sign language is accessible to all children who are deaf, spoken language remains inaccessible to many. Therefore, providing evidence-based professional counseling is crucial to guiding parents in leveraging this golden window for language acquisition. This study aimed to assess the knowledge, attitudes, and practices (KAP) of professionals regarding sign language.
Method: This cross-sectional study involved 199 audiologists (49.2%) and speech-language pathologists (50.8%) who completed an online KAP questionnaire. The survey assessed three domains of sign language in Individuals who are deaf and hard-of-hearing . The data were analyzed using descriptive and inferential statistics, including multiple linear regression, to identify the factors influencing each domain.
Results: There was a strong positive correlation between KAP (p<0.001). Misconceptions, such as the belief that “sign language hinders the speech learning ,” were common. Speech-language pathologists demonstrated better performance in using sign language than audiologists (p<0.001), and younger practitioners exhibited higher levels of knowledge and practice, suggesting the impact of recent training.
Conclusion: This study showed persistent professional beliefs that sign language may reduce children’s motivation to learn speech, overlooking the critical importance of language acquisition during sensitive developmental periods. Since the unbiased attitude of the professional community is influenced by knowledge, enhancing this knowledge base is expected to lead to more effective outcomes regarding the preservation of the golden window for language learning among deaf children.
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3. Most T, Aram D, Andorn T . Early Literacy in Children with Hearing Loss: A Comparison Between Two Educational Systems. Volta Rev. 2006;106(1):5-28.
4. Kramer SE. Hearing impairment, work, and vocational enablement. Int J Audiol. 2008 Nov;47 Suppl 2:S124-30. DOI: 10.1080/14992020802310887
5. Wondwosen Mitiku, Bizuhan Balew. Attitude of School Community Towards the Use of Sign Language for Instructional Purpose. International Journal of Research in Social Sciences and Humanities. 2020;10(4):76-86. DOI: http://doi.org/10.37648/ijrssh.v10i04.008
6. Citation: Nazeri A, Mahmoodi-Bakhtiari B, Fathollahzadeh F, Borna A, Azizi M, Mirzakhani N, et al. Metaphor Skills in Deaf and Hard of Hearing Individuals: A Systematic Review. Aud Vestib Res. 2026;35(1):1-17. 10.18502/avr.v35i1.20574
7. Napoli DJ, Mellon NK, Niparko JK, Rathmann C, Mathur G, Humphries T, Handley T, Scambler S, Lantos JD. Should All Deaf Children Learn Sign Language? Pediatrics. 2015 Jul;136(1):170-6. doi: 10.1542/peds.2014-1632. Epub 2015 Jun 15. Erratum in: Pediatrics. 2015 Oct;136(4):781. DOI: 10.1542/peds.2014-1632
8. Bhavna Singh, Amit Kumar Dubey. Deaf Education and Sign Language: Strategies, Challenges, and Benefits. Naveen Int J Multidiscip Sci. 2025;1(3):75–82. DOI: https://doi.org/10.71126/nijms.v1i3.26
9. Alamri G. Teachers’ Beliefs and Attitudes about Saudi Arabia Sign Language. [Doctoral Dissertation]. Beaumont, TX: Lamar University; 2017.
10. Bonvillian JD, Lee NK, Loncke FT, Dooley TT. Simplified Signs: A Manual Sign-Communication System for Special Populations, Volume 1. Open Book Publishers; 2020. https://doi.org/10.11647/OBP.0205
11. De Villiers PA. The role of language in theory-of-mind development: What deaf children tell us. In: Astington JW, Baird JA, editors. Why Language Matters for Theory of Mind. Oxford: Oxford University Press. 2005. p. 266-297.
12. Murray JJ, Hall WC, Snoddon K. The Importance of Signed Languages for Deaf Children and Their Families. Hear J. 2020;73(3):30, 32. DOI: 10.1097/01.HJ.0000657988.24659.f3
13. Kushalnagar P, Mathur G, Moreland CJ, Napoli DJ, Osterling W, Padden C, Rathmann C. Infants and children with hearing loss need early language access. J Clin Ethics. 2010 Summer;21(2):143-54.
14. Fitzpatrick EM, Stevens A, Garritty C, Moher D. The effects of sign language on spoken language acquisition in children with hearing loss: a systematic review protocol. Syst Rev. 2013 Dec 6;2:108. DOI: 10.1186/2046-4053-2-108
15. Fitzpatrick EM, Hamel C, Stevens A, Pratt M, Moher D, Doucet SP, Neuss D, Bernstein A, Na E. Sign Language and Spoken Language for Children With Hearing Loss: A Systematic Review. Pediatrics. 2016 Jan;137(1). DOI: 10.1542/peds.2015-1974
16. Mousavi SZ, Fathollahzadeh F, Mahmoodi-Bakhtiari B, Nazari A, Mahmoudian S, Asgari A, Nakhostin Ansari N, Borna A. A Practical Guide for Designing and Conducting Knowledge, Attitude, and Practice Studies Focusing on Audio-Speech Field. Journal of Iranian Medical Council. 2026;9(1):261-70. DOI: https://doi.org/10.18502/jimc.v9i1.20500
17. Cripps JH, Cooper SB, Supalla SJ, Evitts PM. Meeting the Needs of Signers in the Field of Speech and Language Pathology: Some Considerations for Action. Commun Disord Q. 2016;37(2):108–16. https://doi.org/10.1177/1525740115576955
18. Sager NG. Exploring the attitudes and beliefs of audiology students towards people who are deaf or hard of hearing [Dissertation]. University of the Pacific; 2019. ProQuest no. 13809016.
19. Wolderufael WM. Attitude of School Community towards the Use of Sign Language for Instructional Purpose in Bahir Dar, Ethiopia. Eur Online J Nat Soc Sci. 2022;11(4):973–83.
20. Zarei F, Dehghani A, Ratansiri A, Ghaffari M, Raina SK, Halimi A, Rakhshanderou S, Isamel SA, Amiri P, Aminafshar A, Mosavi Jarrahi A. ChecKAP: A Checklist for Reporting a Knowledge, Attitude, and Practice (KAP) Study. Asian Pac J Cancer Prev. 2024 Jul 1;25(7):2573-2577. DOI: 10.31557/APJCP.2024.25.7.2573
21. Humphries T, Kushalnagar P, Mathur G, Napoli DJ, Padden C, Rathmann C, Smith SR. Language acquisition for deaf children: Reducing the harms of zero tolerance to the use of alternative approaches. Harm Reduct J. 2012 Apr 2;9:16. DOI: 10.1186/1477-7517-9-16
22. Secora K, Lee B, Smith D, Coppola M. Expert Consensus on the Role of Speech-Language Pathologists in Working With Deaf Children Who Use American Sign Language in the United States: A Classical e-Delphi Study. Am J Speech Lang Pathol. 2025 May 6;34(3):1219-1255. DOI: 10.1044/2025_AJSLP-24-00298
23. Cottrell CE, Medwetsky L, Boudreault P, Easterling BA. Assessing Audiologists' Exposure, Knowledge, and Attitudes when Working with Individuals Within the Deaf Culture. J Am Acad Audiol. 2021 Jul;32(7):426-432. DOI: 10.1055/s-0041-1729221
24. Bettinghaus EP. Health promotion and the knowledge-attitude-behavior continuum. Prev Med. 1986 Sep;15(5):475-91. DOI: 10.1016/0091-7435(86)90025-3
25. Valente TW, Paredes P, Poppe PR. Matching the message to the process: the relative ordering of knowledge, attitudes, and practices in behavior change research. Hum Commun Res. 1998 Mar;24(3):366-85. DOI: 10.1111/j.1468-2958.1998.tb00421.x
26. Richardson H, Koster-Hale J, Caselli N, Magid R, Benedict R, Olson H, Pyers J, Saxe R. Reduced neural selectivity for mental states in deaf children with delayed exposure to sign language. Nat Commun. 2020 Jun 26;11(1):3246. DOI: 10.1038/s41467-020-17004-y
27. Moores DF. Educating the Deaf: Psychology, Principles, and Practices. Boston: Houghton Mifflin; 2001.
28. Kurtzer-White E, Luterman D. Families and children with hearing loss: grief and coping. Ment Retard Dev Disabil Res Rev. 2003;9(4):232-5. DOI: 10.1002/mrdd.10085
29. Mousavi SZ, Maleki M, Maarefvand M, Borna A. Investigating the Effects of Face Mask on Word Recognition Score Test During the COVID-19 Outbreak: Considerations and Limitations. Journal of Modern Rehabilitation. 2024;18(1):55-61. https://doi.org/10.18502/jmr.v18i1.14729
30. Borna A, Mousavi SZ, Fathollahzadeh F, Nazeri A, Harari RE. Applications of Augmented and Virtual Reality in Enhancing Communication for Individuals Who Are Hard of Hearing: A Systematic Review. Am J Audiol. 2024 Dec 2;33(4):1378-1394. DOI: 10.1044/2024_AJA-24-00056
2. Gulati S. Language Deprivation Syndrome. In: Glickman NS, Hall WC, editors. Language Deprivation and Deaf Mental Health. 1st ed. New York: Routledge; 2018. p. 24–53.
3. Most T, Aram D, Andorn T . Early Literacy in Children with Hearing Loss: A Comparison Between Two Educational Systems. Volta Rev. 2006;106(1):5-28.
4. Kramer SE. Hearing impairment, work, and vocational enablement. Int J Audiol. 2008 Nov;47 Suppl 2:S124-30. DOI: 10.1080/14992020802310887
5. Wondwosen Mitiku, Bizuhan Balew. Attitude of School Community Towards the Use of Sign Language for Instructional Purpose. International Journal of Research in Social Sciences and Humanities. 2020;10(4):76-86. DOI: http://doi.org/10.37648/ijrssh.v10i04.008
6. Citation: Nazeri A, Mahmoodi-Bakhtiari B, Fathollahzadeh F, Borna A, Azizi M, Mirzakhani N, et al. Metaphor Skills in Deaf and Hard of Hearing Individuals: A Systematic Review. Aud Vestib Res. 2026;35(1):1-17. 10.18502/avr.v35i1.20574
7. Napoli DJ, Mellon NK, Niparko JK, Rathmann C, Mathur G, Humphries T, Handley T, Scambler S, Lantos JD. Should All Deaf Children Learn Sign Language? Pediatrics. 2015 Jul;136(1):170-6. doi: 10.1542/peds.2014-1632. Epub 2015 Jun 15. Erratum in: Pediatrics. 2015 Oct;136(4):781. DOI: 10.1542/peds.2014-1632
8. Bhavna Singh, Amit Kumar Dubey. Deaf Education and Sign Language: Strategies, Challenges, and Benefits. Naveen Int J Multidiscip Sci. 2025;1(3):75–82. DOI: https://doi.org/10.71126/nijms.v1i3.26
9. Alamri G. Teachers’ Beliefs and Attitudes about Saudi Arabia Sign Language. [Doctoral Dissertation]. Beaumont, TX: Lamar University; 2017.
10. Bonvillian JD, Lee NK, Loncke FT, Dooley TT. Simplified Signs: A Manual Sign-Communication System for Special Populations, Volume 1. Open Book Publishers; 2020. https://doi.org/10.11647/OBP.0205
11. De Villiers PA. The role of language in theory-of-mind development: What deaf children tell us. In: Astington JW, Baird JA, editors. Why Language Matters for Theory of Mind. Oxford: Oxford University Press. 2005. p. 266-297.
12. Murray JJ, Hall WC, Snoddon K. The Importance of Signed Languages for Deaf Children and Their Families. Hear J. 2020;73(3):30, 32. DOI: 10.1097/01.HJ.0000657988.24659.f3
13. Kushalnagar P, Mathur G, Moreland CJ, Napoli DJ, Osterling W, Padden C, Rathmann C. Infants and children with hearing loss need early language access. J Clin Ethics. 2010 Summer;21(2):143-54.
14. Fitzpatrick EM, Stevens A, Garritty C, Moher D. The effects of sign language on spoken language acquisition in children with hearing loss: a systematic review protocol. Syst Rev. 2013 Dec 6;2:108. DOI: 10.1186/2046-4053-2-108
15. Fitzpatrick EM, Hamel C, Stevens A, Pratt M, Moher D, Doucet SP, Neuss D, Bernstein A, Na E. Sign Language and Spoken Language for Children With Hearing Loss: A Systematic Review. Pediatrics. 2016 Jan;137(1). DOI: 10.1542/peds.2015-1974
16. Mousavi SZ, Fathollahzadeh F, Mahmoodi-Bakhtiari B, Nazari A, Mahmoudian S, Asgari A, Nakhostin Ansari N, Borna A. A Practical Guide for Designing and Conducting Knowledge, Attitude, and Practice Studies Focusing on Audio-Speech Field. Journal of Iranian Medical Council. 2026;9(1):261-70. DOI: https://doi.org/10.18502/jimc.v9i1.20500
17. Cripps JH, Cooper SB, Supalla SJ, Evitts PM. Meeting the Needs of Signers in the Field of Speech and Language Pathology: Some Considerations for Action. Commun Disord Q. 2016;37(2):108–16. https://doi.org/10.1177/1525740115576955
18. Sager NG. Exploring the attitudes and beliefs of audiology students towards people who are deaf or hard of hearing [Dissertation]. University of the Pacific; 2019. ProQuest no. 13809016.
19. Wolderufael WM. Attitude of School Community towards the Use of Sign Language for Instructional Purpose in Bahir Dar, Ethiopia. Eur Online J Nat Soc Sci. 2022;11(4):973–83.
20. Zarei F, Dehghani A, Ratansiri A, Ghaffari M, Raina SK, Halimi A, Rakhshanderou S, Isamel SA, Amiri P, Aminafshar A, Mosavi Jarrahi A. ChecKAP: A Checklist for Reporting a Knowledge, Attitude, and Practice (KAP) Study. Asian Pac J Cancer Prev. 2024 Jul 1;25(7):2573-2577. DOI: 10.31557/APJCP.2024.25.7.2573
21. Humphries T, Kushalnagar P, Mathur G, Napoli DJ, Padden C, Rathmann C, Smith SR. Language acquisition for deaf children: Reducing the harms of zero tolerance to the use of alternative approaches. Harm Reduct J. 2012 Apr 2;9:16. DOI: 10.1186/1477-7517-9-16
22. Secora K, Lee B, Smith D, Coppola M. Expert Consensus on the Role of Speech-Language Pathologists in Working With Deaf Children Who Use American Sign Language in the United States: A Classical e-Delphi Study. Am J Speech Lang Pathol. 2025 May 6;34(3):1219-1255. DOI: 10.1044/2025_AJSLP-24-00298
23. Cottrell CE, Medwetsky L, Boudreault P, Easterling BA. Assessing Audiologists' Exposure, Knowledge, and Attitudes when Working with Individuals Within the Deaf Culture. J Am Acad Audiol. 2021 Jul;32(7):426-432. DOI: 10.1055/s-0041-1729221
24. Bettinghaus EP. Health promotion and the knowledge-attitude-behavior continuum. Prev Med. 1986 Sep;15(5):475-91. DOI: 10.1016/0091-7435(86)90025-3
25. Valente TW, Paredes P, Poppe PR. Matching the message to the process: the relative ordering of knowledge, attitudes, and practices in behavior change research. Hum Commun Res. 1998 Mar;24(3):366-85. DOI: 10.1111/j.1468-2958.1998.tb00421.x
26. Richardson H, Koster-Hale J, Caselli N, Magid R, Benedict R, Olson H, Pyers J, Saxe R. Reduced neural selectivity for mental states in deaf children with delayed exposure to sign language. Nat Commun. 2020 Jun 26;11(1):3246. DOI: 10.1038/s41467-020-17004-y
27. Moores DF. Educating the Deaf: Psychology, Principles, and Practices. Boston: Houghton Mifflin; 2001.
28. Kurtzer-White E, Luterman D. Families and children with hearing loss: grief and coping. Ment Retard Dev Disabil Res Rev. 2003;9(4):232-5. DOI: 10.1002/mrdd.10085
29. Mousavi SZ, Maleki M, Maarefvand M, Borna A. Investigating the Effects of Face Mask on Word Recognition Score Test During the COVID-19 Outbreak: Considerations and Limitations. Journal of Modern Rehabilitation. 2024;18(1):55-61. https://doi.org/10.18502/jmr.v18i1.14729
30. Borna A, Mousavi SZ, Fathollahzadeh F, Nazeri A, Harari RE. Applications of Augmented and Virtual Reality in Enhancing Communication for Individuals Who Are Hard of Hearing: A Systematic Review. Am J Audiol. 2024 Dec 2;33(4):1378-1394. DOI: 10.1044/2024_AJA-24-00056
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How to Cite
1.
Borna A, Mousavi SZ, Jarollahi F. The Role of Sign Language in Service Delivery for Individuals who are deaf or hard of Hearing: Knowledge, Attitudes, and Practices of Audiologists and Speech Language Pathologists. Aud Vestib Res. 2026;.
