Counselling in the rehabilitating process for hearing impaired children by parents ’ perspective

Methods: twenty-one parents, whose children with hearing impairment receive speech-language therapy at public services, have been interview. The instrument used for data collection, was a questionnaire with open and multiple choice questions about frequency of family counseling, exploring those issues which were discussed in more depth and the main comprehension difficulties pointed out. The answers were categorized and organized in a digital worksheet in order to do the descriptive analysis.


INTRODUCTION
Hearing loss, regardless of its severity, may represent a major impact on the individual's quality of life, compromising significantly its development while a biopsychosocial being 1 .This is due to the importance that hearing has in the development of oral communication skills, learning and social interaction.This reinforces the need for an early diagnosis and the importance of an appropriate follow-up so that a better use of the neurological maturation period, considered ideal for learning, is guaranteed to the child via auditory stimulation and the consequent acquisition and development of oral language 2,3 .Speech therapy may minimize the impact of hearing loss 4 .In this context, the speech therapist aims to help the patient and its family in reducing the barriers of communication resulting from hearing loss 5 .The term speech therapy assistance means the adaptation of hearing aid electronic devices associated with specialized speech therapy.This adaptation must occur both directly, providing the child with a maximum benefit of its residual hearing, and indirectly by guidance and family counseling so that the work involving language be effective in the domestic environment.
In the case of children with hearing loss, there is no doubt that the emphasis on the orientation and family counseling stage is considered essential.It should be performed at all rehabilitation stages aiming to provide an adequate support to the family.Only thus, parents and guardians of children can understand and help to solve the main difficulties that may occur during the development of children.
In general, family guidance should address issues considered essential, namely: hearing, speech and language aspects, use and maintenance of suitable electronic devices, available educational approaches and issues related to education, among many others that may arise from the very need of the child or its family 6 .An effective orientation procedure may help parents to cope better with their feelings, better understanding themselves and the situation they are in, thus ensuring an effective treatment adherence and, consequently, success in the process as a whole.
Based on the foregoing, the need for the speech therapist to understand its role as mediator between deaf children and their families seems clear in order to provide an optimization of hearing environments and oral communication and thus to assist in the development of oral language by ensuring the continuity of adopting therapeutic strategies outside the clinical environment.
Thus, it is necessary that the professional effectively perform not only guidance procedures but also counseling and care, seeking to promote well-being and personal autonomy in confronting difficulties and problems 7 .
It is needed that professionals be empowered to appropriately guide parents, concerning both its contents and the right time to transmit it 8 .Only then, they will be able to understand and play the incentive roles in the child's development, becoming partners with professionals responsible for interventions.
However, how do parents analyze this process of guidance and counseling provided by speech therapists in rehabilitation services of children with hearing loss?Do they often receive guidance?Do they have difficulty in understanding them?Do they apply the guidelines in the familiar environment?What guidelines are more easily absorbed?
Faced with these questions, the purpose of this study was to analyze the procedure of family orientation performed on rehabilitation public services of children with hearing loss considering the perspective of the parents.

METHODS
Obeying ethical principles, all participants were informed verbally and in writing about the research objectives and the collection procedure.Thus, those who felt comfortable in participating in the study signed an informed consent.This study was approved by the Research Ethics Committee of the Health Sciences Center of the Federal University of Paraíba with CAAE opinion no.36439214.1.0000.5188.
This study is quantitative, descriptive and crosstemporal.The study population consisted of 21 parents chosen at random in two public services in the city of João Pessoa-PB.As an inclusion criterion, every parent should have provided their children with speech therapy for at least six months in one of the services in question.
Data collection occurred from September 2014 to January 2015 using a questionnaire specifically designed to meet the objectives of this study, including questions related to speech guidance procedures and the main themes explored in it.Responses were categorized and organized in a digital spreadsheet in order to perform the descriptive analysis using the results in percentage.

RESULTS
Table 1 shows the characterization of parents/ guardians of children attending the institutions participating in the research.Most parents completed high school (52.4%, n=11) and work in the private sector (42.9%, n=9).Table 3 presents data related to the characteristics of the speech therapy conducted with children whose parents were interviewed.It can be seen that the majority was in a hearing rehabilitation for two to five years (61.9%,n=13), the treatments were performed As for the speech guidance, Table 4 shows that among the main issues addressed by speech therapists, those related to language development, speech and communication were mentioned by parents with a frequency of 90.5% (n=19), followed by guidelines on electronic devices (81%, n=17), hearing and hearing loss (52.4%, n=11) and guidance on the schooling process (47.6%, n=10).Persons responsible commented not finding it difficult to understand the guidance (95.2%, n=20) and were unanimous in reporting that they apply the guidelines of the speech therapist, seeking to continue in familiar surroundings the strategies used in the therapeutic process.
According to the findings, among the advice received on language, speech and communication development of children, the most often mentioned by parents were talking to the child always naming figures, objects and people, working speech sounds through onomatopoeia and promoting a greater socialization with their peers and other family members.For minors who do not use electronic hearing aid devices, the guidelines also consider the use of lip reading, face reading and use of sign language as important auxiliary tools for the development of language.
The results concerning the guidance received on electronic devices (HA/CI) show that parents receive information on the importance of the daily usage, periodic exchange of molds, regular review of the functioning of devices, battery charge control and general care related to hygiene and safety.As for children who do not yet use the devices, parents did not receive specific guidelines since they are awaiting the purchase of devices.Nevertheless, all reported knowing its importance for the optimal development of their children.
The information on schooling process that was mentioned the most by parents was the location of the child in the classroom, the importance of individualized planning of educational activities, daily use of hearing aids in the school, follow-up with an educational psychologist, need for an interpreter in the classroom for those who use sign language and the importance of the teacher in ensuring the understanding of academic content by the child.family members actively participate in the sessions, seek information independently and become fluent and active on the children's communication manner 5 .
Regarding the difficulty to understand the guidance provided, 95.2% of parents in this study mentioned having no difficulties.This was considered very positive.Under this assumption, Miguel and Novaes9 report that the understanding and the retention of information provided by health professionals increase the satisfaction of the patient and of its family regarding the adhesion to treatment, at the same time decreasing anxiety.Providing advice to children with hearing loss by the child's family is the responsibility of the speech therapist.This moment is an opportunity to receive and provide knowledge so that the assimilation of hearing loss and the adjustment to this condition is facilitated 10 .However, the fact that the rehabilitation process should take place in the form of a partnership between those who care for and who are cared for, which is a multifactorial process 10 , must not forgotten.
Family orientation is a simple and effective form of therapeutic intervention that contributes significantly to maximize the development of children with special

DISCUSSION
Analyzing the parent perspective on the orientation procedure performed in clinic services, it is clear, according to the data, that it can be considered efficient due to the time of counseling completion, to the references made by parents relating that the orientation is followed in the family environment, parents ensuring that information is easily understood and that it addresses the main issues related to the specificities of rehabilitation of children with hearing loss.
In fact, the systematic transfer of information has been considered as an important factor in ensuring a greater family participation in the speech rehabilitation of children with hearing loss.In a study conducted in 2013, which sought to assess the degree of family involvement in the care of children with hearing loss, family involvement in the therapeutic process ranked as average, indicating that there is a tendency of parents to participate in the sessions putting in practice what was learned in the therapy in the daily lives of their children and seeking the development of basic communication skills.However, the study points out that it has not reached an ideal level of involvement, in which needs in daily life activities regarding self-care, mobility and social function 11 .
Professionals should consider some aspects of the instruction organization, namely: access to the follow-up of the child's needs; support from family and friends; needs and interests of parents; and family background.Considering them, it is possible to perform a focused intervention centered in the family, with its involvement in the adaptation and use of hearing aids and also in the rehabilitation of the child 6 .
Guidelines to the family should address issues related to hearing, speech and language aspects, so that they understand the child's difficulties, provide its development, and define the best way to treat them.Guidance on the use and care of the hearing aid device (HA) is also essential with regard to its functioning, the change of accessories, the manipulation of controls and the possibilities and educational approaches so that parents seek the most appropriate alternatives for children with hearing loss and their families 6 .
Considering the findings of this research, guidelines directed to the family on language stimulation are reported in the literature.According to Pontes, Vitto and Justo 12 , the clarifications should contain information such as talking to the child; organizing the environment to stimulate action and the exploitation thereof; playing and having fun with the child; looking at the child when it tries to communicate or is talking, accepting gestures that often substitute words not yet learned or memorized; using daily interaction situations experienced by parents and children to name objects, actions and people; and expanding produced sentences.Moreover, it is of utmost importance that the hearing aid device is adapted to the child as early as possible and also that a follow-up in a specialized service 13 is conducted so that difficulties arising from sensory deprivation can be minimized, allowing the acquisition and development of language in the expected period 2 .
Therefore, the orientations regarding the adaptation to hearing aid devices are necessary in order to clarify the parents about the advantages that their child will have with its proper use.Together, experts and parents should observe the child's behavior and the benefit that the device is bringing to it.The time it takes to adapt to the device is relative, for it depends on the child and on how those responsible deal with the situation.Therefore, the family should be oriented as to what is their role in encouraging the use of hearing aid devices and, if the child removes the device, they should respect its wishes for some time, trying, however, to put it back 14 .
Regarding the schooling phase of children with hearing loss, it is essential that the speech therapist orient family and teachers, so that both can help the infant to develop its full potential in this new environment.Therefore, one aspect considered crucial in the schooling phase is the continuous participation of parents in speech therapy sessions.At that time, specific guidelines aimed to help them in the educational process of their children must be addressed, helping them to encourage the practice of reading, visits to book fairs and libraries, creating the habit of writing accounts of lived experiences 15 .
Considering the findings of this research, it is clear that the issue related to education has not been valued as it should be in the process of family counseling.Yet, the guidelines referred to by the parents who participated in this study are reported in the literature.According to Brazorotto 15 , upon discussing schools, guidelines on what they should observe in the initial visit and the choice of institution should be stressed, namely: know the school policy regarding special educational needs; question whether the school has any previous experience with deaf children, the possibility of an individualized planning and other resources; verify whether the room has adequate acoustics, room reverberation and position, and whether there are any guarantees that teachers effectively use this resource if the child has a FM system.
It is known that children rely on their caregivers to access sound stimulation environments and manage their daily activities.Thus, the ability to optimize the results of these children depends on the use of approaches focused on family by speech therapists, supporting parents in applying individualized strategies that involve them in solving problems independently.Therefore, it is necessary that professionals have a specialized training, so that they can integrate counseling skills and behavior change in their clinical practice 16 .

CONCLUSION
This study aimed to analyze the family orientation procedure taking into account the parents' perspective on them.The results show that guidelines given may be considered effective, since, besides being provided in all the sessions, they are easily understood and provide relevant information to parents on the main issues reported and suggested in the literature.Moreover, it can be concluded that the procedure adopted provides parents with a sufficient autonomy and a certainty to implement the instructions given, allowing the continuity of strategies applied in familiar surroundings.
Finally, the importance of further studies addressing the topic "speech guidance for children with hearing loss" and with a larger sample than that used in this study is stressed, as this topic becomes essential for the improvement of speech therapy targeted to these subjects.

Table 1 .
Characteristics of parents/guardians of deaf children

Table 2 .
Characteristics of children with hearing loss (n=21)

Table 3 .
Characteristics of speech therapy with children with hearing loss

Table 4 .
Characteristics of speech orientation for parents of children with hearing loss