Introduction
Hearing loss (HL) is one of the global public health issues and affects about 1.6 billion people worldwide (20.3% of the world’s population) [1]. The incidence of HL in Iran was reported to be approximately 3 to 5 newborns per 1000 births [2]. HL in children can interfere with the natural development of prelinguistic behaviors, language, speech, and communication skills. Children with HL are often at risk for delays in all levels of language development and evolution. They face difficulties in pronunciation, word formation, and sentence combination that express thoughts, and the appropriate use of language for communication. This limits their opportunities for social interaction compared to their hearing peers [3, 4].
The development stages of communication, speech, and language in children consist of three stages: Pre-linguistic, emerging language, and advanced language development. In the pre-linguistic stage, three important skills, including vocalization, gesture, and word emergence develop, which are essential for facilitating speech and language growth. During this stage, the child’s auditory skills, such as reacting to environmental sounds, responding to their name, and engaging in conversations, gradually improve [5]. When Children with normal hearing are involved in developing their language and communication skills from birth to age 5, deaf and hard-of-hearing (DHH) children miss their learning opportunities during this critical period of language acquisition, as they are busy with the process of receiving hearing aids and undergoing auditory training [6]. Since children primarily communicated with their parents, especially their mothers, this communication gradually evolves with the emergence of the child’s vocalizations during these interactions. If these vocalizations are not reinforced, the tendency to produce sounds will gradually diminish, while the auditory skill is fundamental for both vocal expression and production [7, 8]. Therefore, increasing mother-child interaction and communication through implementing early intervention programs, such as parenting skills acquisition programs, leads to a reduction in the impact of HL on the child’s language and speech and social communication skills [9].
Several studies have indicated that implementing parenting skill acquisition programs to facilitate parent-child communication affects positively the language and speech development of DHH children [10-12]. Faranak Parent-Child Mother Goose Program (P-CMGP), the Persian-language adaptation of P-CMGP, is an important example of such programs that have effectively contributed to parent-child communication through singing rhymes, songs, lullabies, and stories, along with gestures and their repetition [13, 14]. The P-CMGP, generally used by parents and their children, is currently being implemented in some centers in many countries, such as Canada, Australia, and the United States as part of supportive interventions for DHH children and their families [13-15]. 
Faranak P-CMGP is used to develop the speech and language skills of DHH children under 3 years old [16], to improve the relationship between hearing mothers and DHH children [17], and to enhance the psychological well-being of mothers with DHH children [18]. The impact of the P-CMGP and Faranak P-CMGP on fostering secure attachment and the relationship between mother and DHH children has been reported in several studies [17-21]. The results of studies on P-CMGP have indicated that implementation of this program improves vocabulary and speech skills [22], expressive and receptive language skills [21, 23], parent-child relationships through the use of American sign language (ASL) rhymes [24], emotions regulation between mother and child [20, 25, 26], emotions expression and increased confidence in social situations [19], and children’s communicative ability [22]. 
Utilizing Faranak P-CMGP, especially during the critical developmental period of ages 1 to 5 — offers a valuable opportunity to support the emergence and development of auditory and vocalization skills. Its ease of implementation and active mother-child engagement in online sessions during the COVID-19 pandemic further highlights its potential to strengthen both early communication abilities and the parent-child relationship. The previous studies have examined the effect of the P-CMGP or Faranak P-CMGP on receptive and expressive language skills [21, 23], communication and speech skills [22]. However, to the knowledge of the authors of this study, no research has yet been published to evaluate the effect of the P-CMGP or Faranak P-CMGP on the development of pre-linguistic skills, including auditory and vocalization skills of DHH children. This study assessed the effect of Faranak P-CMGP on the development of auditory and vocalization skills of children who are DHH under 6 years old.

Materials and Methods
In this quasi-experimental design study with pretest, posttest, and follow-up, subjects were recruited from two early intervention centers for DHH children and their families in Borazjan City and Ganaveh City of Bushehr Province, Iran. They were selected through a convenience sampling method and divided randomly into two groups, an intervention group and a control group. 

Study participants 
The sample size was calculated based on an 80% power, a 5% α error, information from similar studies, and with a likelihood of dropout in each group. Mothers of DHH children were aware of the goals of this study, and informed written consent was obtained from all participants. Overall, 53 DHH children under 6 years old with their mothers (27 in the intervention group and 26 in the control group) were included in this study. The included children did not have any other disabilities except hearing impairment, and they were fitted with hearing aids or cochlear implants (CI). The participants had not previously attended in similar intervention classes. Children who had an average sentence length of more than two words and an auditory age of over three years were excluded. Therefore, 27 mother-child dyads  in the intervention group and 26 dyads in the control group were allocated.

Study measurements 
The Persian version of the questionnaires, including Purdy Auditory Behavior in Everyday Life (ABEL) and Kishon-Rabin Production of Infant Scale Evaluation (PRISE) were used to measure the development of auditory and vocalization skills in the two intervention and control groups before the intervention, as well as one month and four months after the intervention. 

Auditory Behavior in Everyday Life (ABEL)
In this study, the Persian version of the 23-item, Purdy ABEL (2002) assesses the auditory development in Persian language children through three factors: auditory-oral, auditory awareness, and conversational/social skills. Each factor consists of 10, 8, and 5 questions, respectively, using a 5-point scale, with responses ranging from zero (strongly disagree) to four (strongly agree). The total score of these three factors reveals the range of ABEL score from 0 to 92 [27]. Oryadi-Zanjani et al. in their psychometric study of the Persian version (2018) calculated the total consistency of the questions using Cronbach α, resulting in a score of 0.95 [28]. The reliability of the scale was calculated using the Cronbach α in this study. The Cronbach α value for ABEL was 0.765. It is worthwhile to mention that all questionnaires were completed by mothers of both groups.

Production of Infant Scale Evaluation (PRISE)
In this study, the Persian version of the 11-item, Kishon-Rabin PRISE (2004, 2005) assesses the development of pre-verbal vocalizations in Persian-speaking children aged 3 months and older. The PRISE contains questions that use a 5-point scale, with responses ranging from zero (strongly disagree) to four (strongly agree). The total score reveals a range of PRISE scores from 0 to 44 [29, 30]. Oryadi-Zanjani et al. in their psychometric study of the Persian version (2018) calculated the internal consistency of the questions using Cronbach α, resulting in a score of 0.88. There was also a strong positive correlation between the total scores of the questionnaire and the child’s age (r=0.791) [31]. In the present study, the reliability of the scale was calculated using the Cronbach α. The Cronbach αvalue for PRISE was 0.732. All questionnaires were completed by mothers of both groups.

Study Interventions

Faranak Parent-Child Mother Goose Program (Faranak P-CMGP)
Faranak P-CMGP, the Persian-language adaptation of P-CMGP, focuses on promoting the parent-child relationship and bonding through singing songs, rhymes and stories. In the Faranak program, the content from Iranian culture, including songs, rhymes and lullabies, along with selections from Faranak program book series, was used [32]. The program begins with a warm welcome, encouraging mothers to sit down on mats in a circle and hold their children on their laps. Before the program starts, toys are given to the children to play with, but no toys are used during the performance of the program. The program is based on the mother’s rhythmic singing with the child together through hand movement, as they look at each other (face-to-face), with eye contact, touch, cuddling, and smiling. In each session, two to three different new rhymes, songs, and lullabies were performed, gradually using longer pieces. Previous songs were also repeated for the mother and child as a reminder. Two teachers were involved in implementing the program: The primary teacher was responsible for singing rhythmic, simple, and child-friendly songs, rhymes, and lullabies for mothers and children, and the second teacher collaborated in singing and facilitated the sessions. Throughout the program, teachers, mothers, and children sing songs together, say rhymes together.
Mothers with DHH children in the intervention group participated in 30 weekly sessions (one-hour) of Faranak P-CMGP. Initially, the program was held by the group participation of mothers and their children at two centers and online with the primary teacher for six sessions. Subsequently, due to the COVID-19 pandemic, the remaining sessions continued online via WhatsApp in five small mother-child groups. Because of the children’s interest in technology, the online sessions attracted their attention and their families. Meanwhile, the COVID-19 pandemic resulted in the halting of the routine care for both groups. The training program content is presented in Table 1.



Data analysis
The data were analyzed by repeated measures analysis of variance, with α error of 0.05, using SPSS software, version 21.0.

Results
A total of 53 mothers with DHH children participated in this study. The mean age and standard deviation of the mothers were 33.55±3.72 years. In terms of the educational level of participants, 41 mothers had a diploma (77%) and 12 bachelor’s degree (23%). There was no significant difference between the age and education levels of the mothers in the two groups (P>0.05). The characteristics of the children are shown in Table 2.



As shown in Table 2, nearly all children had severe to profound HL. There was no statistically significant difference between chronological age and hearing age of the children, as well as the communication mode between mother and child (verbal/sign language; P>0.05). Statistically significant difference was found in the gender type of children in the two intervention and control groups (P=0.01). All children were fitted with CI or hearing aids.
All variables were normally distributed. Before conducting repeated measures analysis of variance, the sphericity of changes within and between subjects was confirmed using the Greenhouse-Geisser correction. Table 3 shows the results of repeated measures analysis of variance for comparing the effect size and mean scores of auditory skill development and its three factors in children of the two groups at three times of measurements: pre-test, post-test, and follow-up.



The result of the repeated measures analysis of variance showed statistically significant differences were found in the mean score of auditory skill development between the children of the two groups: an intervention group and a control group (P<0.001). Furthermore, statistically significant differences were found in the mean scores of auditory skill development and its three factors: auditory-oral, auditory awareness and conversational/social skills (P<0.001 in all instances) in the intervention group between the pre-test and post-test. There was no statistically significant difference in the mean scores of auditory skill development and its three factors: auditory-oral, auditory awareness and conversational/social skills in the intervention group, one month and four months after the intervention during follow-up (P>0.05 in all instances). There was no statistically significant difference in the mean scores of auditory skill development and its three factors: auditory-oral, auditory awareness and conversational/social skills (P>0.05 in all instances) in the control group.
Based on the Eta squared coefficient, 30% of the changes between the scores of DHH children in the two groups are attributed to the intervention (Table 3). 
Table 4 shows the results of repeated measures analysis of variance comparing the effect size and mean scores of vocalization skill development in DHH children between the two groups at three times of measurement: Pre-test, post-test, and follow-up.
The result of the repeated measures analysis of variance showed statistically significant differences were found in the mean score of vocalization skill development between the children of the two groups: an intervention group and a control group (P<0.001). Furthermore, a statistically significant difference was found in the mean scores of vocalization skill development in the intervention group (P<0.001) between the pre-test and post-test. There was no statistically significant difference in the mean scores of vocalization skill development in the intervention group, one month and four months after the intervention during follow-up (P>0.05). There was no statistically significant difference in mean scores of vocalization skill development in the control group (P>0.05).
Based on the Eta squared coefficient, 32% of the changes between the scores of children in the two groups are attributed to the intervention (Table 4). 



Discussion
The 30 weekly training sessions of the Faranak P-CMGP led to significant improvements in the auditory skill development, including its three factors: auditory awareness, auditory-oral, and conversational /social skills, as well as in vocalization skill development in the intervention group in the post-test and follow-up. The present study demonstrated that the Faranak Program has a significant effect on the development of auditory and vocalization skills of children, and the effectiveness was statistically significant after at least four months of follow-up.
Parenting skill acquisition programs play a vital role in auditory skill development in supporting DHH children, as these programs by fostering key pre-linguistic abilities, including auditory awareness and auditory-oral communication skills. In this study, these two skills showed a greater increase than conversational/social skills, which may be attributed to the Faranak group program involving rhythmic songs and rhymes along with gestures. This program led to increased children’s awareness and appropriate responses to environmental sounds and their own voices, facilitating successful communication. Additionally, the children may achieve statistically significant improvement in auditory skills by responding to their name, whispering, talking at a normal voice level, and asking questions about the sounds heard around them.
The Faranak program also led to a statistically significant and noticeable improvement in vocalization skill among DHH children, enabling them to focus on their mother’s facial expressions and the manner of her speech during everyday communication and the long-term repetition of songs. This focus led them to achieve the production and perception of vocalizations and two-syllables, the imitation and repetition of words, as well as the production of rhythms, all of which are the foundation for both expressive and receptive language skills. 
Previous studies have examined the effect of the P-CMGP or Faranak P-CMGP on receptive and expressive language skills [16, 21, 23] and literacy skills [24]. However, , to the knowledge of the knowledge of the authors of this study, no research has yet been published to evaluate the effect of the P-CMGP or Faranak P-CMGP on the development of pre-linguistic skills, including auditory and vocalization skills of DHH children. In all the mentioned studies, songs, rhymes, and lullabies have been used as tools to help parents build stronger relationships with their DHH children. The findings of these studies revealed the effect of the Faranak P-CMGP on facilitating language development in early childhood, which is the foundation for improving literacy skills. For example, Snoddon (2011) interviewed hearing parents of deaf toddlers engaging in ASL P-CMGP and reported that the parents observed immediate changes in their toddlers’ behavior, such as hand movements, happy facial expressions, laughing, and babbling, when the toddlers were exposed to ASL rhyme and rhythmic songs [24]. 
To examine other effective intervention strategies during the preverbal period, it is possible to refer to the results of studies conducted by Razmi et al. [33] and Ghanavatinejad et al. [34]. For instance, Razmi et al. applied “online dialogic parent-child book reading” as an intervention strategy to improve the preverbal and listening skills of deaf children under 3 years old. The results demonstrated that the online dialogic parent-child book reading program had a statistically significant effect on listening and preverbal skills, including imitation, pointing, joint attention, and taking turns [33]. The results of Razmi et al. and the present study emphasized the significance of mother interactions with DHH child in early childhood for improving auditory and communication skills in children who are deaf. In another study, Ghanavatinejad et al. applied a “rhythmic and movement songs and educational lullabies program” to improve listening comprehension and speech intelligibility [34]. They reported effect sizes of 0.45 and 0.48 following the implementation of the rhythmic and movement songs and educational lullabies program on listening comprehension and speech intelligibility in children with CI under 3 years old. In the present study, the effect sizes obtained after implementation of the Faranak program on auditory and vocalization skills were 0.30 and 0.32. Despite the use of songs, rhymes, and lullabies along with gestures in both studies, the possible reason for the greater effect sizes observed in Ghanavatinejad's study may be attributed to the in-person format of rhythmic and movement songs and educational lullabies program. 

Conclusion
The results of this research demonstrated statistically significant and positive effect of the Faranak P-CMGP on the development of pre-linguistic skills, including auditory and vocalization skills of DHH children. The interactions created during this program through songs, rhymes and lullabies along with gestures and body movements led to successful communication between children and their mothers, and their environments, as well as imitation and repetition of the sounds and words. The Faranak program was more effective when early intervention rehabilitation programs for DHH children were implemented continuously. The present study also indicated that the development of auditory awareness and auditory-oral skills of DHH children, as well as the strengthening of communication skills between parents, especially mothers, and their children can be easily achieved by implementing the Faranak program. However, further research with larger sample size, conducted in an in-person format and in suitable environment with minimal environmental stimuli, seems necessary. It is recommended that educators of DHH children and early intervention specialists benefit from this program alongside other educational and rehabilitation programs for DHH children. Additionally, holding training courses aimed at increasing parents’ awareness of the behaviors of DHH children is also recommended to provide appropriate responses to the children’s behavior and language. Moreover, conducting online group programs can be a suitable alternative for mothers who are unable to attend face-to-face sessions for any reason, allowing them to benefit from the Faranak program.

Study limitations
There are some limitations in this study. This research was conducted during the COVID-19 pandemic, characterized by social isolation and the closure of centers, making access to large samples challenging. Participation in the Faranak program, which provided opportunities for communication between mothers and mother-child dyads, may have had a greater impact on outcome measures during that time of reduced social connections for individuals, including mothers with DHH children, compared with post-COVID-19 pandemic under normal conditions. Furthermore, as the sessions were held online (audio and video) due to COVID-19, the effect size of the in-person format program may differ from what was estimated through the online program. Since the study was conducted in two small cities in Iran, the results cannot be generalized to all Iranian children or children worldwide.  

Ethical Considerations

Compliance with ethical guidelines
The study was approved by the Research Ethics Committee of Shiraz University, Iran. Informed written consents were obtained from all mothers of children with hearing loss. 

Funding
This article is self-funded and did not receive any grant from funding agencies. This research was extracted from master’s thesis of Hakimeh Sadeghikhah at the Department of Psychology and Education of Exceptional Children, Faculty of Education and Psychology, Shiraz University, Shiraz, Iran.

Authors' contributions
Conceptualization, Somayeh Sadat Sadati Firozabadi, Guita Movallali, Hakimeh Sadeghikhah; Implementing P-CMGP, Data collection and Data analysis, Tahereh Soleimanieh-Naeini, Hakimeh Sadeghikhah; Writing and editing, Somayeh Sadat Sadati Firozabadi, Tahereh Soleimanieh-Naeini, Guita Movallali. Final approval, All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors gratefully thank the participation of mothers and children who are DHH, and the collaboration of authorities the collaboration of authorities of the two early intervention centers for DHH children and their families in Borazjan and Ganaveh cities in Bushehr, Iran in conducting this research. The authors are also grateful to Ms. Nayere Mehdipour Shahrivar and Prof. Enayatollah Bakhshi for their invaluable guidance.


 

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