Systematic Review of Studies on Visual Phonics

Abstract

Visual Phonics is a multisensory teaching tool that has the potential to improve reading outcomes. The purpose of this systematic review is to examine studies on Visual Phonics to provide a comprehensive understanding of the effects on code-related skills. Thirteen studies met the inclusion criteria. The results demonstrate that Visual Phonics can be an effective strategy to teach code-related skills for at-risk hearing kindergarteners and d/Deaf and hard of hearing students, regardless of the degree of hearing loss, grade placement, communication method, home language, and prevalence of an additional disability. A number of these studies contain limitations such as a small sample size, difficulty with obtaining a randomized sample, lack of a control group, and difficulty with the generalization of findings. Therefore, there is a need for additional research on the effects of Visual Phonics and its progression to becoming an evidence-based practice.

Keywords

deaf/hard of hearing exceptionalities reading intervention strategies evidence-based practices

Reading is a complex process and many d/Deaf and hard of hearing (d/Dhh) students have reading difficulties (Easterbrooks et al., 2008). Most students with severe to profound hearing loss graduate from a high school with approximately fourth-grade reading level (Paul et al., 2013; Qi & Mitchell, 2012; Traxler, 2000), and the annual growth of reading for d/Dhh students is 0.3 grade per year (Harris et al., 2017). However, it seems to be improving with recent advances in newborn hearing screening and hearing aid technologies (Harris et al., 2017; Mayer & Trezek, 2018).

Two broad domains of code-related skills (e.g., phonemic awareness, letter names, grapheme-phoneme correspondence, and phonics) and language-related skills (e.g., morphology, semantics, and syntax) play a significant role in reading development and inadequacies in any of these areas contribute to poor reading achievement (Hoover & Gough, 1990; Luft, 2018; Mayer & Trezek, 2015). These two domains appear to have a differential influence on reading acquisition. For example, during the early stages of reading development, code-related skills play a critical role, but once the children learned the code, language-related skills become more influential (Whitehurst & Lonigan, 1998).

Two national reading reports found that code-related skills are critical for students’ early reading success (National Early Literacy Panel [NELP], 2008; National Reading Panel [NRP], 2000). The National Early Literacy Panel (NELP, 2008) reviewed the literature on promoting young children’s early literacy skills from birth to age 5 years and identified six variables that are strongly related to later conventional literacy skills: (a) alphabet knowledge; (b) phonological awareness; (c) rapid automatic naming of letters or digits; (d) rapid automatic naming of objects or colors; (e) writing or writing name; and (f) phonological memory. In addition, the National Reading Panel (NRP, 2000) found that phonemic awareness and phonics are the most important precursors of later reading success. They are highly correlated with each other and the most important aspects of early reading instruction.

Phonemic awareness is defined as “the ability to notice, think about, and work with the individual sounds in spoken words” (Armbruster et al., 2001, p. 1). Phonemic awareness instruction has greater effects on learning reading when combined with phonics instruction. The best way to teach phonemic awareness and phonics is through explicit and systematic instruction (NRP, 2000). According to the NRP, phonics programs have the greatest impact when they begin in kindergarten or first grade, instruction continues for 2 to 3 years, and all lesson delivery systems (i.e., tutoring, small group, or whole class) are effective. It is important to highlight that phonics instruction is not a complete reading program, and it should be integrated with other components of balanced reading instruction such as phonemic awareness, reading sight words, fluency, vocabulary, reading comprehension strategies, and enhanced language experiences (NRP, 2000).

The NRP (2000) identified several different systematic and explicit phonics instruction programs. The results of the analysis demonstrated that all types of systematic phonics programs had statistically significant effects, but they did not differ from each other. However, the NRP particularly mentioned Jolly Phonics and Letterland, which use hand motions and actions to reinforce learning. Using gestures is beneficial for memory, and research showed that students with speech and language impairments recalled information better when using gestures than when only using phonological coding (Morrison et al., 2008):

The motivational value of associating letters with interesting characters or hand motions and incorporating this into activities and games that are fun is important for promoting young children’s learning. If the task of teaching letters is stripped bare to one of memorizing letter shapes and sounds, children will become bored and easily distracted and will take much longer to learn the associations. (NRP, 2000, pp. 2–125)

In the field of deaf education, there is an ongoing debate whether the reading development of d/Dhh students is qualitatively similar to or different from the reading process of hearing students (Andrews & Wang, 2015). All of the doubts revolve around the role of sound-based phonological skills (Paul, 2014). There are three general perspectives: (a) reading development of d/Dhh students is qualitatively similar to that of children with typical hearing (Paul et al., 2013); (b) deaf children read through a visually based process such as fingerspelling and sight word recognition (Allen et al., 2009), and (c) d/Dhh children’s reading process depends on their auditory access to spoken language, thus d/Dhh children with functional hearing read as hearing children (Easterbrooks et al., 2015).

The qualitative similarity hypothesis states that the reading acquisition process of d/Dhh students is developmentally similar to that of typical literacy learners (Paul et al., 2013). Thus, critical components of the reading curriculum and reading foundations should be the same for both d/Dhh and typical literacy learners. However, traditional instruction that is based on speech and hearing may not be adequate for some d/Dhh students (Narr, 2006). Evidently, phonological instruction does not need to depend on speech intelligibility and/or hearing (Narr, 2006; Paul & Wang, 2012). For example, some d/Dhh students access phonological information through their residual hearing and others benefit from multisensory strategies (e.g., auditory, visual, and tactile/kinesthetic) (Narr, 2006). Therefore, supplementary instructions are required to improve the literacy outcomes of d/Dhh students (Mayer & Trezek, 2015; Paul et al., 2013).

The role of code-related skills in learning to read is well-documented (Adams, 1990; Mayer & Trezek, 2015; NELP, 2008; NRP, 2000; Paul et al., 2013; Snow et al., 1998). Instructional methods that are supported by research findings are crucial elements of a successful reading program, and effective teaching strategies lead to tremendous increases in students’ learning; however, teachers need to be knowledgeable about what to teach and how to teach (Hartman et al., 2019; Morrison et al., 2008; Snow et al., 1998). Easterbrooks et al. (2006) found that teachers of d/Dhh students had conflicted views about phonemic awareness and phonics instruction. Half of the teachers did not believe that these activities would be appropriate for d/Dhh students and teachers did not have adequate training on how to teach phonemic awareness and phonics (Easterbrooks et al., 2006; Easterbrooks & Stephenson, 2012). Also, Donne and Zigmond (2008) found that teachers of d/Dhh students spent on average only 1.2 min a day on phonemic awareness and phonic activities.

An alternative technique that has been used to supplement traditional phonics instruction for d/Dhh students is Visual Phonics (Trezek, 2017). Visual Phonics, also known as See the Sound/Visual Phonics, is a multisensory teaching tool that has been used to teach early reading skills of the alphabetic principle, phonemic awareness, and phonics (Trezek & Wang, 2017). Visual Phonics has 46 hand cues and corresponding written symbols for the sounds of English (Waddy-Smith & Wilson, 2003). Visual Phonics hand cues mimic the articulatory features of sounds and include the features of the manual American Sign Language alphabet as well as the English alphabet (Morrison et al., 2008). These features provide visual and kinesthetic access to phonological information. For example, the hand cue for the /p/ sound is produced in two steps. First, the hand is made a flat “o” shape by connecting the thumb and with the top four fingers near the corner of the mouth. Second, all five fingers are opened when the sound /p/ is produced (Syverud et al., 2009).

The primary goal of Visual Phonics is to clarify the letter-sound relationships between spoken and written words. When a child masters the target spoken phonemes, the use of Visual Phonics fades (Beal-Alvarez et al., 2012). It is important to highlight that Visual Phonics is not a communication method, language, or reading curriculum (Wang et al., 2008). Visual Phonics is a classroom-based teaching tool that is most effective in conjunction with a phonics-based reading curriculum (Morrison et al., 2008; Trezek, 2017).

Visual Phonics has been used for almost 40 years, and a growing and promising body of research supports the effectiveness of Visual Phonics for d/Dhh students (Beal-Alvarez et al., 2012; Guardino et al., 2011; Narr, 2008; Smith & Wang, 2010; Syverud et al., 2009; Trezek et al., 2007; Trezek & Hancock, 2013; Trezek & Malmgren, 2005; Trezek & Wang, 2006; Tucci & Easterbrooks, 2015; Wang et al., 2013), undergraduate students who were learning Italian (Cihon et al., 2013), and hearing students who are at risk for reading difficulties (Cihon et al., 2008; Gardner et al., 2013).

Trezek and Wang (2017) reviewed the intervention research in peer-reviewed journals between 2000 and 2016 to evaluate the evidence-based practices in deaf education for the Council of Exceptional Children’s standards. The authors found 30 available studies within seven categories, and 12 studies investigated explicit phonological/phonemic awareness and phonics instruction with or without Visual Phonics. Studies without Visual Phonics revealed mixed evidence whereas studies with Visual Phonics found positive evidence about the effectiveness of the intervention. The authors found three studies that met the standards (Beal-Alvarez et al., 2012; Trezek & Malmgren, 2005; Tucci & Easterbrooks, 2015), and Visual Phonics is rated as a potentially evidence-based instruction tool (Trezek & Wang, 2017).

Also, Tucci et al. (2014) conducted a literature review on strategies for teaching grapheme-phoneme correspondence to d/Dhh students. The authors found six effective strategies, and one of them was Visual Phonics. Similarly, Entwisle et al. (2016) examined the emergent literacy interventions and found that Visual Phonics supports the phonological development of preschoolers with cochlear implants. However, there has not been a review of the effects of Visual Phonics on the development of code-related skills across populations, and findings have not been synthesized to draw conclusions about the intervention. Therefore, the purpose of this systematic review is to analyze all relevant studies on Visual Phonics to ascertain the effects on the development of code-related skills to conclude for whom it mostly benefits. Moreover, this review aims to identify the limitations of existing research and directions for future research.

Method

Search Procedures

A literature search was conducted following similar procedures used by Luckner and colleagues (Luckner & Cooke, 2010; Luckner & Handley, 2008; Luckner & Urbach, 2012). A multistep process was used to locate studies for this review. First, a set of search terms (e.g., Visual Phonics, See the Sound, phonics intervention, and reading instruction) was used across multiple search engines (e.g., EBSCOhost, Academic Search Complete, Education Search Complete, Eric, PsycINFO, and Google Scholar) without restrictions on publication year, research methodology, or types of participants. Second, an ancestral search of each identified study’s reference list was conducted to include as many studies as possible. To be included the study

had to be published in a peer-review journal. (Unpublished manuscripts, dissertations, master theses, books, book chapters, and conference proceedings were excluded.);

participants had to have consisted of PreK to 12th grade students; and

must have used Visual Phonics as the independent variable and must have contained at least one dependent variable measuring reading components.

Results

Even though there were no restrictions on publication year, all articles were published between 2005 and 2015. Even though there has been anecdotal support for Visual Phonics since its creation in 1982, this technique had almost no research base (Woolsey et al., 2006). Woolsey and colleagues made a call to close this research-to-practice gap, and this gap has been closing since 2005. Although the literature search was conducted in 2020, no studies after 2015 met the inclusion criteria.

Thirteen studies were identified and included in the present study. Table 1 presents a summary of the studies. Each included study was reviewed and coded. First, studies were placed into one of four population categories: (a) typical hearing students who were at risk for reading failure (n = 2), (b) d/Dhh middle and high school students (n = 2), (c) d/Dhh primary school students (n = 4), and (d) d/Dhh preschoolers (n = 5). After the placement of studies, each study was coded according to the authors and year, research method, participants, degree of hearing loss, age, grade, gender, settings, communication mode, home language, intervention and duration, dependent variables and measures, key findings, effect sizes, implications, and future research.

Table 1.

Summary of Selected Intervention Research.

Source	Method	Participants and setting	Intervention and duration	Dependent variables and measures	Key findings and effect size	Implications
Cihon et al. (2008)	A nonconcurrent multiple baselines across participants and sounds with an embedded multielement design additional support with pretest-posttest	Five hearing kindergarteners who are at risk for reading failure. Three females and two males who ranged in age from 5 to 6 years old. General education One student deaf in one ear (Al)	A generic lesson plan was created and intervention sessions at least 3 times per week for approximately 10–12 min each in a small group of two to four students. Total intervention time varied across participants from 3.5 to 5.5 hr, depending on the participant’s performance.	DIBELS and CBM	Post-intervention gains for each participant in almost all DIBELS assessment areas. Most gains in word use fluency	Visual Phonics intervention can be appropriate for children who are falling behind with the regular reading curriculum.
Gardner et al. (2013)	A nonconcurrent multiple baseline design	Six hearing kindergarteners who were at risk for reading failure (one female and five males) General Education	A generic lesson plan (Cihon et al., 2008) 5 months with maintenance measures given 1 week and/or 1 month after instruction	Letter sound relations DIBELS subtests of initial sound fluency and letter naming fluency. and CBM	All participants improved their knowledge of letter-sound relations. Five participants made enough progress to change their risk status	Visual phonics can be an effective tool for teaching kindergarten students to initial phonic skills.
Trezek and Malmgren (2005)	A quasi-experimental/pre- and post-test design with a comparison group	23 middle school students Grade 6 to 8 11 to 15 years old Slight to profound hearing loss Total Communication Self-contained d/Dhh program One auditory neuropathy	Decoding A curriculum supplemented with the phonics treatment package (Visual Phonics, Baldi, Pictorial glossary) 45 min of daily instruction over 8 weeks	Scores on curriculum-based measures of sound identification, word reading, and pseudoword decoding. Researcher-developed post-test and generalization test.	Pretest scores were strongly correlated with the degree of hearing loss. Significant gains in grapheme-phoneme identification in isolation, grapheme-phoneme identification within-word, and word decoding regardless of the level of hearing loss. A highly significant difference between the performance of the treatment and comparison students on the posttest (z = −2.936, p = .003), and generalization test (z = −2.941, p = .003)	Visual Phonics is effective in teaching phonological skills to d/Dhh students.
Trezek and Hancock (2013)	Pretest -posttest /experimental	127 d/Dhh students (28 elementary, 42 junior high, and 57 high school students) 50 females and 77 males 7 to 19 years old Second grade and higher Mild to profound Bilingual communication philosophy ASL is the primary mode of instruction Sign bilingual setting (state school for the deaf) 40% of students have additional disabilities	Decoding A curriculum supplemented with Visual Phonics. Students received 40 min of daily instruction for over 3 years.	The curriculum-based researcher created phoneme isolation, word reading, and pseudoword decoding measures are used on pretest, posttest, and generalization probes similar to Trezek and Malmgren’s (2005) study.	Pretest–posttest difference for all three measures is large and have statistically significant effects. Identifying phonemes in isolation d = 1.75 Phoneme blending d = 2.18 Word reading d = 2.93	d/Dhh students in a sing bilingual setting including with additional disabilities can benefit code-related reading instruction with Visual Phonics.
Trezek and Wang (2006)	Pretest-posttest/experimental design	13 d/Dhh kindergarten and first-grade students (seven students were African American and six of them are Hispanic) 5 to 7 years old Severe to profound (two first-graders wore cochlear implants) Total communication Self-contained d/Dhh program	Reading Mastery curriculum supplemented with Visual Phonics. The intervention period was over 8 months	Scores on Wechsler Individual Achievement Test-II subtests: word reading, pseudo-word decoding, reading comprehension	Gains in word reading, pseudo-word reading, and reading comprehension. The gain on the word reading test was equivalent to 4.33 months, and the gain on the pseudoword test was 9 months. Word reading d = −1.600	Further support for use of VP
Trezek et al. (2007)	pre-test/post-test experimental design	20 d/Dhh kindergarten and first-grade students 5 to 8 years old 70% (n = 14) Caucasian, 25% (n = 5) African American, and 5% (n = 1) Asian. Mild to profound (10 had cochlear implants) students Simultaneous and oral communication Self-contained d/Dhh program	A phonics-based district developed the LACES curriculum supplemented with Visual Phonics. 90 mins of daily instruction during 1 school year.	Scores on Dominie Reading and Writing Assessment Portfolio (sentence writing phoneme, sentence writing spelling, phonemic awareness segmentation, phonemic awareness deletion, phonics onsets, and phonics rimes subtests.	The statistically significant difference between pre- and posttest scores on all six subtests. Sentence Writing Phoneme d =1.37 Sentence Writing Spelling d =1.49 Phonemic Awareness Segmentation d = 1.21 Phonemic Awareness Deletion d = 1.47 Phonics Onsets d = 1.30 and Phonics Rimes d = 1.17	d/Dhh students can demonstrate improvements in beginning reading skills as measured by standardized assessments with Visual Phonics instruction.
Narr (2008)	Posttest only	10 d/Dhh students in kindergarten through third-grade mixed-grade classroom 5 to 9 years old Self-contained d/Dhh program Moderate to profound (one student had cochlear implants and nine hearing aids) sign language or sign supported English	Eclectic reading instruction supplemented by Visual Phonics. Students received daily instruction and intervention ranged from 1.5 to 3 years.	Dependent variables were phonological awareness and decoding. Researcher- developed phonological awareness and decoding task based on Sterne & Gotswami.	Students were able to use phonological information to make rhyme judgments and decode words, but there was no significant interaction between reading ability and length of time using Visual Phonics instruction rhyme judgments d = 1.84 decoding task d = 1.60	Reading instruction using Visual Phonics may be a viable tool for teaching phonological awareness and decoding skills to some d/Dhh students.
Guardino et al. (2011)	A multiple case study	Six d/Dhh students in kindergarten through fifth grade (two Latino and four African American) One female and five males 7 to 12 years old Mild to profound (two students have cochlear implants, three hearing aids, and one Starkey bone conductor) Self-contained d/Dhh program Oral philosophy	Teach Your Child to Read in 100 Easy Lessons, a direct instruction reading curriculum supplemented by Visual Phonics. 30 min a day, 3 times a week for 10 weeks.	Researcher-developed number of nonsense words read correctly on weekly lists and qualitative data from intervention journals kept by tutors.	All students made gradual gains in pseudoword reading accuracy.	This study extends the previous findings to a different population.
Smith and Wang (2010)	A single case study	A 4-year-old male deaf child (Hispanic) Profound hearing loss with a cochlear implant Total Communication (Use of some spoken and signed language) Speaks Spanish at home A state-funded school for the deaf	The modified version of The Fountas and Pinnell Kindergarten Phonics Curriculum supplemented with Visual Phonics. The intervention lasted 6 weeks long, at least 4 times a week for 15–20 min daily.	Post-test scores on revised Ling 6 sound test, identifying beginning consonant sounds, identifying first letters	Significant increases in phonological awareness	The use of Visual Phonics cues with a phonics curriculum can support phonological awareness and provide an alternative source of information about spoken and written language.
Beal-Alvarez et al. (2012) (Study 1)	A multiple baseline across content design	A 5-year-old female preschooler (Hispanic) Self-contained d/Dhh program Profound hearing loss (hearing aids) Sign language Spanish used at home	Foundations for Literacy Curriculum supplemented with Visual Phonics 10 weeks 30 min a day, 4 times a week	Researcher-developed measures of grapheme/ phoneme correspondences	All grapheme-phoneme correspondences are learned. A strong effect POD = 5.9%	Children with minimal speech perception can learn grapheme-phoneme correspondences with using Visual Phonics.
Beal-Alvarez et al. (2012) (Study 2)	A multiple baseline across content design	4 years old Three preschoolers (two female and one male) Severe to profound All children used hearing aids ASL (n =1) Combination of speech and sign Self-contained d/Dhh program	Foundations for Literacy Curriculum supplemented with Visual Phonics 4 times a week for 23 weeks	Researcher-developed measures of grapheme/phoneme correspondences and word decoding	All participants mastered grapheme-phoneme correspondence very quickly. POD was between 0% and 2%. All children correctly decoded all the phonemes and taught words but not any of the novel words.	Children with various levels of speech perception and degrees of hearing loss can learn grapheme-phoneme correspondences with using Visual Phonics.
Wang et al. (2013)	A case study	Three female d/Dhh preschoolers Three White 3 to 4 years old Moderate to profound (one hearing aid and one cochlear implant) Total communication A private preschool One language processing disorder	The Reading Mastery I curriculum supplemented with Visual Phonics and smart board technology. 40- or 50-week intervention	Standardized assessments were conducted before, during, and after the intervention. (a) TOPEL, (b) PALS, and (c) Woodcock-Johnson Test of Achievement-III (letter-word identification, spelling, passage comprehension, and word attack subtests)	All students showed improvements in early reading skills. Overall reading levels at or above age level.	Preschool d/Dhh students with different degrees of hearing loss can improve early reading skills with Visual Phonics in combination with a direct phonics-based curriculum.
Tucci and Easterbrooks (2015)	Multiple baselines across content design	Three d/Dhh preschoolers Two male and one female One African American, one Asian, and one Hispanic 4 to 5 years old Moderate to profound (one cochlear implant and two hearing aid) Total Communication A day school for the deaf	Foundations curriculum supplemented by Visual Phonics. 1 hr per day, 4 days per week, for 25 weeks.	Researcher-developed measures of letter-sound correspondences, and initial sound identification	Increased performance in letter-sound correspondence and initial-sound identification POD was 0% for letter-sound correspondence and initial-sound identification for all participants.	d/Dhh students could learn letter-sound correspondence and initial-sound identification when Foundations was supported with VP handshapes.

Note. DIBELS = Dynamic Indicators of Basic Early Literacy Skill; CBM = Curriculum-Based Measures; ASL = American Sign Language; POD = Percent of overlapping data; TOPEL = Test of Preschool Early Literacy; PALS = Phonological Awareness Literacy Screening.

Population Categories

Five studies investigated Visual Phonics with preschoolers with a total of 11 students and revealed significant improvements in early reading skills during these fundamental years (Beal-Alvarez et al., 2012; Smith & Wang, 2010; Tucci & Easterbrooks, 2015; Wang et al., 2013). All preschoolers improved their early reading skills of phonological awareness and letter-sound knowledge. Six studies evaluated the effects of Visual Phonics with students in primary grades (n = 60) and found positive outcomes (Cihon et al., 2008; Gardner et al., 2013; Guardino et al., 2011; Narr, 2008; Trezek et al., 2007; Trezek & Wang, 2006). Two of the six studies that focused on primary grades targeted hearing kindergarteners who are at risk of reading failure (Cihon et al., 2008; Gardner et al., 2013). Finally, the last two studies included older d/Dhh students (n = 150) in middle or high school settings (Trezek & Hancock, 2013; Trezek & Malmgren, 2005). These students in later grades still benefited from phonemic awareness and phonics instructions because their skill development in those areas was slower than that of typically developing learners.

Participants

There were total of 221 participants. The sample size of the studies varied between one (Beal-Alvarez et al., 2012; Smith & Wang, 2010) and 127 (Trezek & Hancock, 2013). Participants include 11 hearing kindergarteners who are at risk of reading failure and 210 d/Dhh students in preschool through high school settings. Nine studies (70%) reported on the participants’ gender. Among those 157 participants, 62 students (40%) were female, and 93 students (60%) were male. Participants’ age or age ranges were reported in all 13 studies (100%), and the age range was 3 to 19.

Race and ethnicity

Students’ race and ethnicity were reported in seven studies (54%) with 47 participants. Seventeen students were African American, 17 students were White, 11 students were Hispanic or Latino, and two students were Asian.

Degree of hearing loss

Students with different degrees of hearing loss (slight to profound) were included in the intervention studies. No relationship was found between degrees of hearing loss and the effectiveness of Visual Phonics intervention. Studies reported that students with different levels of hearing loss equally benefited from the intervention and demonstrated gains in code-related skills (Guardino et al., 2011; Narr, 2008; Trezek et al., 2007; Trezek & Wang, 2006; Tucci & Easterbrooks, 2015; Wang et al., 2013). For example, Trezek and Wang (2006) calculated correlations for each student’s degree of hearing loss and difference scores from pretest to posttest, and the analysis revealed nonsignificant results.

Additional disability

Four of the 13 studies (31%) reported participants with additional disabilities, accounting for 52 participants (24% of all participants). Studies found that the presence of an additional disability did not appear to be a factor that affected the benefits of Visual Phonics intervention (Trezek & Hancock, 2013; Wang et al., 2013). In a study by Trezek and Hancock (2013), approximately 40% of the participants had an additional disability:

The categories of documented disabilities included attention deficit/hyperactivity (n = 14), autism (n = 3), emotional disturbance (n = 6), mental retardation (n = 9), other health impairments (n = 10), specific learning disability (n = 20), and visual impairment (n = 1). (p. 394)

The authors analyzed data in two phases: (a) paired sample t tests and Pearson correlations and (b) structural equation modeling. The results showed that there was no statistically significant difference related to the existence of an additional disability.

Cochlear implants

Seven studies were reported participants who were fitted with cochlear implants (n = 18), and the intervention was effective for those students (Guardino et al., 2011; Narr, 2008; Smith & Wang, 2010; Trezek et al., 2007; Trezek & Wang, 2006; Tucci & Easterbrooks, 2015; Wang et al., 2013).

Functional hearing

The Early Speech Perception (ESP) test requires children with hearing loss to discriminate words only through audition. The results place them into one of four speech perception categories: no pattern perception (ESP 1), pattern perception (ESP 2), some word identification (ESP 3), and consistent word identification (ESP 4). Children who have functional hearing defined as those children who scored ESP 3 or ESP 4. Two studies reported students without functional hearing. Beal-Alvarez et al. (2012) and Tucci and Easterbrooks (2015) concluded that Visual Phonics intervention was effective for all students regardless of their functional hearing status.

Communication mode

Most participants used Total Communication, a combination of sign and speech. Two studies included students who used oral philosophy (spoken English only) (Guardino et al., 2011; Trezek et al., 2007). Also, three studies included signing participants. Trezek and Hancock (2013) conducted the first large-scale study (n = 127) over 3 years in a sign bilingual educational setting. During the intervention, vocalizations were never used, and instructions were delivered via sign language. Students demonstrated favorable gains in sound-based phonological skills. In addition, Beal-Alvarez et al. (2012) examined preschoolers who were using sign language in their two studies, and they learned all targeted grapheme-phoneme correspondences. Furthermore, Tucci and Easterbrooks (2015) concluded that the Visual Phonics intervention was effective for signing d/Dhh students. Moreover, some of the studies reported participants, who were coming from Spanish speaking homes and equally benefited from the Visual Phonics intervention (Beal-Alvarez et al., 2012; Guardino et al., 2011; Smith & Wang, 2010; Trezek et al., 2007; Trezek & Wang, 2006; Tucci & Easterbrooks, 2015). In conclusion, Visual Phonics intervention is effective for all communication modes such as spoken language, total communication, and sign language.

Setting

All studies were conducted in the United States. The setting varied across 13 studies. Two studies (15%) reported hearing participants in general education classrooms. For d/Dhh students, one study (8%) reported a private preschool; one study (8%) was in a day school for the deaf; two studies (15%) were conducted in a state school for the deaf, and seven studies (54%) reported a self-contained d/Dhh program.

Design

Five of the 13 studies (38%) used single case experimental designs, three studies (23%) used case study designs, four of them (31%) used pretest-posttest experimental designs, and only one study (8%) used group comparison design.

Intervention

Two of the studies with hearing kindergarteners used a generic Visual Phonics lesson plan as an intervention along with business-as-usual instruction. The other 11 studies with d/Dhh students used a phonics-based reading curriculum supplemented with Visual Phonics. The explicit and systematic phonics-based reading programs supported with Visual Phonics were: Corrective Reading-Decoding A curriculum, Foundations for Literacy, Teach Your Child to Read in 100 Easy Lessons, Fountas and Pinnell Kindergarten Phonics Curriculum, The Reading Mastery I program, and LACES. The duration of the intervention ranged between 6 weeks to 3 years.

Dependent Variables and Key Findings

All 13 studies investigated the same or different dimensions of code-related skills and effects of Visual Phonics intervention, and all of them found strong evidence that students showed improvements in their phonemic awareness, phonological decoding, and letter-sound correspondence skills (see Table 1 for reported effect sizes). The authors used a combination of standardized, curriculum-based, and researcher-developed measurements. Two studies with children with typical hearing used Dynamic Indicators of Basic Early Literacy Skills (DIBELS) subsets. All students improved their scores on DIBELS subtests, and some of them even changed their risk status from at risk to low risk. Only two studies with d/Dhh students (Narr, 2008; Trezek & Wang, 2006) tried to relate phonological awareness and decoding improvements with reading comprehension, but they found mixed results. In a study by Narr (2008), students from a mixed-grade classroom were selected to participate. The classroom teacher was already using Visual Phonics as a part of her business-as-usual reading instruction for almost 10 years. The researcher used the length of time in literacy instruction with Visual Phonics and students’ current reading levels as independent variables and only collected data on phonological awareness and decoding. One sample t test showed significant gains in phonological awareness and decoding measures. However, no relationship was found between the length of time in literacy instruction and performances on these tasks as well as their current reading level. In addition, limited data were available on reading comprehension in a study by Trezek and Wang (2006). Even though there was an improvement from pretest to posttest, it was not possible to calculate statistical tests or grade equivalent gains on reading comprehension tests.

Discussion

The purpose of this article was to examine and summarize the research conducted on Visual Phonics across populations. This review identified 13 studies that examined the effects of the Visual Phonics intervention on 11 hearing kindergarteners and 210 d/Dhh students’ reading-related skills. In general, this review demonstrates that the phonics-based instruction supplemented with Visual Phonics is effective for d/Dhh students to improve their phonological awareness, letter-sound correspondences, and phonological decoding skills regardless of their degree of hearing loss, amplification use, mode of communication, gender, and having an additional disability. However, mixed results were reported on students’ performance related to reading comprehension.

The intervention was also effective for general education hearing kindergarteners who were at risk for reading failure, and d/Dhh students in all grade levels from preschool to high school in various settings. These findings support the NRP’s (2000) conclusion that code-focused instruction is beneficial for all children in early grades and older struggling learners. Montgomery (2008) suggested that Visual Phonics contributes to building literacy skills while using multisensory inputs, so it can be adapted to different instructional situations. Visual Phonics can be used for children who have hearing loss, communication disorders, and reading difficulties; also, it is suitable for any typical child as an early literacy skill improvement tool (Montgomery, 2008).

The role of phonological skills in d/Dhh children’s literacy development is debated especially for students without functional hearing who use American Sign Language (Paul, 2014). The results support the qualitative similarity hypothesis and provide evidence for the effectiveness of Visual Phonics for all d/Dhh students with or without functional hearing (Beal-Alvarez et al., 2012; Trezek & Hancock, 2013; Tucci & Easterbrooks, 2015).

Limitations

There are potential limitations of the study. First, even though a comprehensive review of the literature was conducted, it is possible that some relevant studies were not included because the search terms were not sufficient. Second, the focus was on peer-reviewed studies and dissertations or master theses, unpublished studies, and reports, book chapters, or conference proceedings were not included. Third, there is a possibility that other scholars may have synthesized included studies differently since reviewing, summarizing, and developing a table were interpretive processes. Fourth, not all studies reported effect sizes. Because of the small sample sizes, it was impossible to conduct rigorous statistical analysis. Finally, researcher-developed measures are limitations because these assessments might not be effective to capture actual gains made by students.

Implications for Practice

Consistent with previous research, the present study found that Visual Phonics in combination with a direct phonics-based curriculum can be used effectively to teach the early literacy skills of phonemic awareness, letter-sound correspondences, and phonological decoding to kindergarten students without disabilities and d/Dhh students with or without additional disabilities in preschool through high school settings regardless of their level of hearing loss or functional hearing. Visual Phonics can be delivered in all three instructional formats: one-on-one, small group, and/or large group.

In addition, NRP (2000) highlighted the motivational value of using hand motions to teach phonological skills. Visual Phonics has an advantage because it is not a complete phonics program. Visual Phonics can be easily incorporated into any existing programs, so teachers do not need to learn a completely new phonics program that can be expensive and time-consuming. Therefore, Visual Phonics is inexpensive, easy to learn, and a lifelong intervention tool.

Recommendations for Future Research

All reviewed studies highlighted the necessity of further research. For example, researchers discussed limitations such as a small sample size, difficulties with randomized sampling procedures, lack of a control group, and limited generalization of findings. Because hearing loss is a low-incidence condition, these limitations are common throughout the research in the field of d/Dhh education. Investigators recommend that future research needs to incorporate more students with different degrees of hearing loss in well-designed experimental studies with rigorous statistical analyses over a longer period. Also, standardized measures should be used to obtain more accurate information on student achievement. In addition, the long-term benefits of this type of intervention should be explored with a link to other reading skills such as fluency, vocabulary, and reading comprehension. Finally, investigation of other areas of the English language, such as morphology, syntax, and semantics, may be beneficial to better understand the effects of the intervention (e.g., see discussion in Wang et al., 2017).

Conclusion

The importance of phonology-based factors for d/Dhh students is mixed with respect to the effectiveness of instruction in this area (Easterbrooks & Stephenson, 2012). Several scholars in the field of deaf education have downplayed the role of sound phonology of English in reading development (Allen et al., 2009) whereas others believe that phonological skills in English are associated with higher levels of English reading for d/Dhh students (Paul et al., 2013).

This review provides support for the qualitative similarity hypothesis that argues the curriculum should be roughly the same for all children, regardless of individual differences, but instruction should be differentiated based on students’ individual needs (Paul et al., 2013). Since 2005, there has been a growing and promising body of research about Visual Phonics as an evidence-based instructional strategy for teaching phonemic awareness and phonics to d/Dhh and hearing students. It was found that Visual Phonics had significantly positive outcomes on phonemic awareness and phonics instructions for d/Dhh students regardless of the degree of hearing loss, grade placement, communication method, home language, and prevalence of additional disability, and functional hearing status (Guardino et al., 2011; Narr, 2008; Smith & Wang, 2010; Syverud et al., 2009; Trezek et al., 2007; Trezek & Hancock, 2013; Trezek & Malmgren, 2005; Trezek & Wang, 2006; Tucci & Easterbrooks, 2015; Wang et al., 2013) and for hearing kindergarteners who are at risk for reading difficulties (Cihon et al., 2008; Gardner et al., 2013).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ayse N. Kart

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