RESEARCH Open Access Childhood disability in …...RESEARCH Open Access Childhood disability in...

DiGiacomo et al. International Journal for Equity in Health 2013, 12:7http://www.equityhealthj.com/content/12/1/7

RESEARCH Open Access

Childhood disability in Aboriginal and TorresStrait Islander peoples: a literature reviewMichelle DiGiacomo1,2*, Patricia M Davidson1, Penelope Abbott3,4, Patricia Delaney3, Tessa Dharmendra1,Sarah J McGrath1, Joanne Delaney3 and Frank Vincent3

Abstract

Introduction: Aboriginal and Torres Strait Islander children have higher rates of disability than non-Indigenouschildren and are considered doubly disadvantaged, yet there is very little data reflecting prevalence and serviceaccess to inform design and delivery of services. Failing to address physical, social, and psychological factors canhave life-long consequences and perpetuate longstanding health disparities.

Methods: A narrative literature review was undertaken to identify peer reviewed literature describing factorsimpacting on the prevention, recognition, and access to support and management of disability in IndigenousAustralian children.

Results: Twenty-seven peer-reviewed journal articles met inclusion criteria. The majority of articles focused on thehearing loss and learning disabilities consequent of otitis media. Few articles reported data on urban or metropolitanIndigenous populations or described interventions. Individual/community-, provider-, and systems level factors wereidentified as impacting on recognition and management of disability in young Indigenous children.

Conclusions: Given the burden of childhood disability, the limited literature retrieved is concerning as this is a barometerof activity and investment. Solutions addressing childhood disability will require collaboration between health, social andeducational disciplines as well as an increased investment in prevention, identification and promotion of access.

Keywords: Aboriginal and Torres strait islander, Childhood, Disability, Early intervention

IntroductionEarly childhood is a critical period that can influence arange of health and social outcomes throughout the lifecourse. In Australia, an economically prosperous and gen-erally healthy nation, Aboriginal and Torres Strait IslanderPeoples (hereafter, Indigenous) suffer worse health, disad-vantage, and disability comparable to many developingnations [1]. Dispossession, disempowerment, and racismcontribute to adverse outcomes [2,3]. Indigenous childrenwith a disability are considered ‘doubly disadvantaged’, andfailing to address physical, social and psychological factorscan have life-long consequences [4,5]. High rates of child-hood disability in Indigenous children fuel health

* Correspondence: [email protected] for Cardiovascular and Chronic Care; Faculty of Health, University ofTechnology Sydney, PO Box 123, Broadway, NSW 2007, Australia2Curtin University, Curtin Health Innovation Research Institute, Perth 6845,AustraliaFull list of author information is available at the end of the article

© 2013 DiGiacomo et al.; licensee BioMed CenCreative Commons Attribution License (http:/distribution, and reproduction in any medium

inequities and should be an important focus of attentionfor policy makers and health professionals.

Disability in Indigenous AustraliansFor the purposes of this paper, the term disability refers tothe long-term physical, mental, intellectual, or sensoryimpairments that hinder full and effective participation insociety on an equal basis with others [6]. Rates of disabilityin Indigenous adults and children are higher than in non-Indigenous Australians. Indigenous adults are 1½ timesmore likely than non-Indigenous Australians to have a dis-ability or long-term health condition, more than 3 timesas likely to have an intellectual disability, and more thantwice as likely to require support meeting self-care, com-munication or mobility needs [7,8]. Similarly, Indigenouschildren are 30% more likely to require assistance withlearning or communicating, have a core activity need forassistance, and a profound or severe disability, than age-matched non-Indigenous children [3]. Up to 27% of

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Indigenous children in Western Australia (WA) havelimitations in vision, hearing, or speech [9]; a statisticlikely reflecting Australia having one of the highest ratesof otitis media (OM) in the world [10,11]. Other studieshave identified lower scores on performance and develop-ment in young Indigenous children as compared to non-Indigenous children [12,13].Despite these disparities, data on prevalence, type, and

service access among Indigenous children in Australia islimited, particularly in urban populations [11,14,15]. Onlyrecently has the Australian national census sought infor-mation on disability for Indigenous individuals under theage of fifteen [3]. Problems with Indigenous identification,high non-response rates, and different conceptualisationsof disability may mask hidden disability and contribute tounder-reporting [14,16].

Low service useIn addition to little prevalence data, which precludesdiscussion of service access in children, it has beenreported that few Indigenous people with a disability ac-cess services. In 2008–09, only 5% of users of specialisedsupport services were Indigenous [17], indicating thatthey are not participating in available programs [18]. InNew South Wales, which has the largest population ofIndigenous people in Australia, and the largest popula-tion with severe or profound core activity limitations,rates of service provision to Indigenous people are belowthe national average [17]. Barriers in accessing supporthave been attributed to remoteness, social marginalisa-tion, cultural attitudes towards disability, and culturallyinappropriate services [19].Although not directly targeting disability, cost effective

quality early interventions, such as pre-school, have beenreported to be key points where development indicatorscan trigger support, potentially making a difference tolife-long outcomes [20,21]. In Australia, just 25% of Indi-genous children aged 3.5-4.5 attend any formal earlychildhood services and these children are least likely tohave access to high quality pre-school education [22,23].

Consequences of lack of supportThis lack of support and therapies in the early years of lifecan have devastating consequences for the child, theirparents/carers, family, and community; contributing tocycles of disadvantage. Investment in the early yearsthrough policies that address social determinants of healthhas potential to reduce social, economic, and health dis-parities within a generation [2,24]. The need to informsuch policies through measuring and understanding theproblem and assessing the impact of action has driven thisreview. Specifically, we aimed to answer the followingquestion: What are the factors impacting on the preven-tion, recognition, and access to support and management

of disability in Indigenous Australian children? To answerthis question, we conducted an integrative narrative re-view to ascertain the state of the science, potentialsolutions, and gaps in services and research.

MethodsData collectionWe undertook an integrative review which is a methodthat incorporates disparate sources, methods, and typesof literature and facilitates development of comprehen-sive accounts of phenomena [25] while summarising lit-erature, identifying gaps, and recommending furtherresearch in a given area [26]. In contrast to a systematicreview, an integrative review, although conducted withsystematic methods, discusses and summarizes literatureon a particular topic, without generating a pooled sum-mary or focusing on questions of efficacy.The literature search strategy was designed and

conducted in consultation with a health librarian in Au-gust 2011. Peer-reviewed literature was identified viasearches of Medline, PsychInfo, Cumulative Index toNursing and Allied Health Literature (CINAHL), Indi-genous Australia, Australian Public Affairs InformationService-Aboriginal and Torres Strait Islanders (APAIS-ATSIS), Aboriginal and Torres Strait Islanders Health(ATSIHealth), the Australian Indigenous Health InfoNet,Education Resources Information Center (ERIC), andCochrane Library databases and the Google Scholarsearch engine. Database searches were limited to articleswritten in English and published between 1990 – July2011. Additional literature was identified via retrievedstudies’ reference lists. Literature was included if it1) centred on Indigenous Australian children or families;2) centred on issues surrounding Indigenous Australianchildren with a disability or impairment; and 3) depictedaspects of prevention or recognition of disability or ac-cess to support, treatment, or management. Articleswere excluded if they did not report separately on Aus-tralian Aboriginal and Torres Strait Islander Peoples ordid not concern childhood disability. Search terms wereMedical Subject Headings (MeSH) terms and keywordsincluding derivations of child, (newborn, baby, babies,infant, infants, children, childhood) and Indigenous (In-digenous, Australian Indigenous, Australian Indigenous,Aborigine, Oceanic ancestry group) and disability (intel-lectual disability, learning disorder, language disorder,communication disorder, hearing impaired, hearing loss,hearing disorder, visually impaired, mentally disabled,developmental disability, attention deficit, disruptive be-havior disorders, child behavior disorders, child develop-ment disorders, motor skills disorders, cognitiondisorder, speech, language disorders, autism, autistic dis-order, Aspberger syndrome, physical disability) tailoredto relevant databases. For the inclusive purposes of this


review, the term disability encompassed developmentaldelay, intellectual disability, sensory impairment, andphysical disability. Theoretical and empirical papers wereincluded and no restrictions were imposed on study de-sign or methodology.The grey literature was searched using broad terms

depicting Indigenous children with disability after identify-ing websites of relevant government and non-governmentorganizations in Australia, as well as Australian univer-sities and research centres. We contacted key authors torequest copies of relevant reports not available via theinternet. Additional grey literature was sourced using thedatabases listed above, the internet search engine Google,and via hand searching of reference lists.

Data evaluation and analysisTwo authors independently reviewed all titles andabstracts for relevance to the review topic. They obtainedfull copies of retained articles for detailed examination todetermine suitability for inclusion. Any disagreementbetween authors was resolved by a third author. Twoauthors extracted data from retrieved documents, into acustomised data extraction spreadsheet with columnsdepicting disability focus, methodological and interventionfeatures (if available), aims, key findings, and informationpertaining to prevention, recognition, and access to sup-port and management of disability. Strength of findings ofprimary sources were evaluated via MeInyk and Fineout-Overholt’s Levels of Evidence ranking system [27]. Inaddition, observational studies were evaluated using theSTrengthening the Reporting of OBservational studies inEpidemiology checklist (STROBE) checklist [28], andintervention studies were appraised via the TransparentReporting of Evaluations with Nonrandomized Designs(TREND) checklist for non-randomised health and socialinterventions [29]. Analysis proceeded with categorisationof data guided by the research question and the ChronicCare framework, which summarizes elements for improv-ing care in health systems at individual, community, prac-tice and organization levels [30].

ResultsThe literature search resulted in 189 peer-reviewed ar-ticles reporting both empirical studies and theoreticalarticles. Following application of inclusion and exclusioncriteria, twenty-seven articles were included in the re-view (Figure 1). The majority of peer-reviewed articles(n = 20) described otitis media (OM) and hearing loss inIndigenous peoples. With the exception of studies de-scribing national data, just four articles reported data onurban or metropolitan Indigenous populations. Nearlytwenty per cent of the articles (n = 6) were over ten yearsold. The majority of articles reported on descriptive andobservational studies (n = 11) (Table 1). STROBE scores

ranged from 4 (indicating provision of little detailon which to judge veracity of findings) to 21 (indica-ting provision of detailed information) [28]. The meanSTROBE score was 14.7 out of a possible 22 (67%).Just four intervention studies were identified and these

addressed stigma, sound amplification (management),and screening (recognition) (Table 2). All reportedbeneficial outcomes, three of which involved teachingstrategies and/or hearing support in classrooms withevaluations of literacy, communication, and other educa-tional outcomes. The mean TREND score was 11.9 outof a possible 22 (54%).Five discussion papers (Table 3) and six literature

reviews were identified, yet just one provided a detaileddescription of the review process (Table 4). Threereviews centred on hearing impairment and OM exclu-sively (Table 4). We identified six reports from the greyliterature (Table 5). Although we endeavoured to ascer-tain factors impacting on prevention, recognition, andaccess to support and management of disability, we didnot identify articles describing prevention other than acall for collaborative development of health-relatedpromotional material to minimise ear infections [31].Following this summative account of literature identi-fied, we now provide a narrative summary using theframework of the Chronic Care model’s elements forimproving care in health systems at multiple levels.

Individual and community-related factorsDifferent conceptualisations of disabilityPerceptions of Indigenous disability affect recognitionand access to support and management. Reports highlighted differing views between Indigenous and non-Indigenous people’s conceptualisations of disability, im-pairment, and behaviours that may hinder identification,an important step towards early intervention that canimprove a child’s social, language, and communicationdevelopment and contribute to school readiness [32].For example, Indigenous people with a disability mayexperience stigma in their communities and for some,independence may not be prioritised [32]. These viewsmay hinder help-seeking behaviours.While Indigenous families and communities may not

perceive a child as having a disability, ‘labelling’ Indigen-ous people with a disability as ‘the Other’ and as aspecialised field is apparent within the mainstream Aus-tralian service system [33]. Hence, appreciating thesedifferences in meanings and understandings of disabilityconcepts among both service providers and Indigenouspeoples is important to obtaining better understandingsof needs, expectations, and preferences.Although challenges to access are a feature of disability,

this is likely aggravated among Indigenous families wheredisclosure of a problem may lead to unwanted attention

Search:Peer-reviewed journal

articles on disability in

Australian Indigenous children

Articles identified via database searchN = 189

Titles and abstract screened for relevanceN = 125

Articles included in reviewN = 27

Duplicates removed N = 29

Not relevantN = 64

Did not report on Australian Indigenous childrenN = 47

Did not report on disabilityN = 9

Not peer-reviewedN = 8

Articles assessed for eligibilityN = 97

Articles excludedN = 68

Not full paper (conference abstracts) N = 4

Figure 1 Literature selection process.


on circumstances and social situation [14]. Fear and dis-trust of organisations, marginalisation, and disadvantagehave made some Indigenous people reluctant to accesssupport and services [18]. Many individuals fear that theirchildren will be taken from them [34,35]. Other factorsassociated with being Indigenous that impact on the ex-perience of disability include the diversity within Indigen-ous communities, importance of family, community, andculture, social isolation associated with disability, and so-cial disadvantage which alienates some families from ser-vice providers [19].

Systems-related recognition factorsRegular hearing screening programmes in schools areessential to detect and prompt appropriate treatmentfor children [31]. Although screening for hearing lossis important, factors impacting on this taking placein schools include the schools’ awareness of this service,relationships developed between service providers, Indi-genous perceptions of hearing loss and disability,funding, staff turnover, training and equipment, healthpolicy, and access to health facilities [31].

Need for culturally appropriate screening instruments andpsychometric toolsCulturally appropriate assessments are difficult to achieveas standard intellectual and social assessments have

been found to be culturally-biased. D’Aprano et al. [13]found that Indigenous children were well behind non-Indigenous children using the Brigance developmentalscreening tool. The language, cultural relevance, and itsadministration method limit its use. This study hashighlighted a need to adapt an appropriate instrument toguide developmental surveillance and monitoring in re-mote Australian Indigenous communities. It has beenargued that the criteria developed for the allocation tospecial schooling may constitute indirect racial discrimi-nation against Indigenous students and there is a need forassessment and evaluation by Indigenous educators of thebasis on which Indigenous students are placed in specialclasses at school [36].

Provider-related factors affecting recognitionSuch complexities made professionals reticent to imposelabels, in some cases. This can result in an under-appreciated level of disability and some Indigenousstudents not receiving the support they need. It wasdiscussed that if a label can facilitate additional support,a culturally appropriate professional assessment andintervention was warranted, but not otherwise [19].

Cultural training and workforce issuesA significant proportion of literature on hearing loss inchildren centres on the learning environment and

Table 1 Observational studies

First Author(year)

Disability/impairment

Design Level ofEvidence

STROBEscore

Population Setting Methods

Aithal, S. (2008) Hearing Observational IV 17.5 Indigenous children (n = 15): 1) English-speaking w/no hearing loss; 2) learningESL w/no hearing loss; 3) ESL withhearing loss; mean age 13

Island 80km northof Darwin

Hearing test

Gunasekera,H.(2007)

Hearing Cluster survey of consecutiveprimary health consultations

IV 21 Primary care consults on OM inIndigenous (n = 280) and non-Indigenous (n = 8,510) aged 0–18 years

Australia secondary analysis of nationalsurvey

Gunasekera,H.(2009)

Hearing Cross-sectional survey VI 18 AMS medical practitioners managingchildren's OM in December 2006

Australia Postal survey

Howard, D.(1991)

Hearing mixed-method; ethnography VI 8.5 23 Aboriginal students in multi- gradeAboriginal class

Darwin observation, physiologicalassessment, teacherinterviews & survey

Howard, D.(2006)

Hearing Case study VI 14.5 Urban Aboriginal children Darwin classroom observation andhearing assessment

D'Aprano, A.(2011)

Development tool assessment via cross-sectional screening

VI 18 124 Australian Aboriginal children,aged 3–7 years

3 remote communitiesin NT

pediatrician screening usingstandardized tool

Howard, D.(2004)

Hearing Cross-sectional survey VI 14 167 Aboriginal children Remote NT teacher survey and childhearing assessment

Bennett, B.(2010)

Development tool validation within prospectivelongitudinal cohort study

IV 20 55 urban Aboriginal children at 12months of age

Southwest Sydney structured and semi-structured questionnaire;interview; physical exam;social, motor, hearing andspeech, eye handcoordination, and reasoning

Aithal, V.(2006)

Hearing Observational; Cross- sectionalhearing test; comparison group

VI 14.5 36 Aboriginal children from Tiwi Islandswith OM and some hearing loss; (meanage 10); Control group - 62 childrenfrom Darwin (normal hearing; meanage 13)

Island 80km northof Darwin and Darwin

Hearing test

Nelson, A(2007, 2004)

General disability Mixed-method(qualitative/quantitative)

VI 12.5 Urban Indigenous families & OTs Brisbane Interviews, focus groups,questionnaires

Partington, G.(2006)

Hearing Observational VI 4 >500 Indigenous students preschool -year 3 (ages 5–8) from 16 schools, >80teachers and assistants

Western Australia multi-modal observation,evaluation spanning 2 years;teacher training andinterviews, ear healthassessment, achievementrecords, data mapping ofclassroom observations

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Table 1 Observational studies (Continued)

First Author(year)

Aims Key Contributions Conclusions/recommendations Strengths Weaknesses Category

Aithal, S. (2008) To examine the effect of hearingloss and native-languagephonology on learning English byAustralian Indigenous children

ESL children has slowerrecognition time of Englishwords; hearing impairmentrelated to OM made it evenmore difficult for ESL children

Phonological awareness programs need tobe part of a reading program frompreschool for ESL Indigenous children

Inclusion of control group Sampling not described; useof interpreter not discussed

R

Gunasekera,H.(2007)

To assess clinical management ofOM in Aboriginal children

Indigenous kids more likely tohave severe OM, but not morelikely to receive oral antibiotics,ear syringing, referral tospecialist.

Indigenous children are 5 times more likelyto be diagnosed with severe OM than non-indigenous children, but management isnot substantially different; inconsistent withestablished national guidelines.

Representative national surveyof health care consultations;randomized sampling of healthconsultations

Prevalence and incidenceinfeasible; no data onprogress, treatment of cases;age range only 0-18

A

Gunasekera,H.(2009)

To compare the burden of OMmanaged by AMS practitioners andthe availability of specialist earhealth services in rural/remoteversus urban Australian settings

More cases managed/week inrural remote and morereported relevant services werenot available locally; audiologywaiting times longer than therecommended 3 months; equalproportions of urban/ruralreported ENT waiting timelonger than the recommended6 months

Need for adequate funding of visitingservices in rural/remote settings andoutreach programs delivered by AboriginalHPs, increasing frequency of audiologistvisits to rural and remote locations,proportionate hearing service expenditureshould reflect the population’s need aswell as rurality indices.

Nearly 3/4 of AMS’srepresented; audiologyassessments had face validitywith clinicians an in line withinternational

55% response rate; noindependently verification ofwaiting times; no comparison

A

Howard, D.(1991)

To investigate relationship betweenAboriginal children's hearing lossand their learning.

30% of children had hearingloss; teacher- oriented learningbehavior associated withattendance and achievement

Hearing loss appears to magnify difficultiesin cross-cultural education; need toconsider how schools currently meetneeds of Aboriginal students with hearingloss and how Western schooling can bealtered to better meet these needs.

integration of interview andsurvey data; Aboriginalteaching staff included;observation longitudinal

limited information onrecruitment, interviews; singleobserver

R

Howard, D.(2006)

To identify cultural differences inattentiveness between Aboriginaland non- Aboriginal children; toexamine differences betweenurban hearing and hearing-impaired Aboriginal children.

Cultural differences inattentiveness style in Aboriginalstudents with and withouthearing loss may lead toinaccurate assessments byassessors.

Without formal screening, cross-culturalmisunderstanding is likely to inhibitappropriate teacher referrals of Aboriginalchildren for hearing tests; regular schoolhearing screening for Aboriginal children isneeded; Teachers to be aware of possiblebehavioral indicators of Aboriginalchildren’s hearing loss.

mixed method; integrated data small sample; single observer R

D'Aprano, A.(2011)

To trial the Brigancedevelopmental screening tool toidentify Australian Aboriginalchildren at risk of developmentaldisability and requiring assessment.

All children scored below thecut-off for likely havingdevelopmental disabilities oracademic delays; all wellbehind their age peers

Language and cultural relevance, and themethod of administration limit the use oftool; need to adapt appropriate instrumentto guide developmental surveillance andmonitoring in remote Australian Aboriginalcommunities that incorporates families

Aboriginal research staffinvolvement; tool sensitive topsychosocial disadvantage

remote-only; recruitment notdescribed; language barriersfor some participants; culturalrelevance not established forsome

R

Howard, D.(2004)

To asses extent of social andeducational difficulties across crosscultural classrooms.

Aboriginal children withbilateral hearing loss participateless in class, are moredisruptive, and require moreone to one assistance

Ensure access to Aboriginal teachers andtutors; train Aboriginal teachers and tutorsin issues around hearing loss; provideprofessional development to non-Aboriginal teachers.

teacher report integrated withobjective tests; Aboriginalteaching staff included

remote-only; definitiveconclusions implausible; nosample size or samplingframe information

R-Q

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Table 1 Observational studies (Continued)

Bennett, B.(2010)

To determine appropriateness ofGriffiths’ Mental DevelopmentalScales to assess development incohort of urban Aboriginal children

No significant differencesexcept Gudaga performancescores were significantly lessthan the reasoning scores inthe Griffiths’ standardizationsample

Griffiths’ Mental Developmental Scales maybe appropriate for urban Aboriginal infants.

Questionnaire administration inperson; physician report; 100%response rate; prospective

small sample frame; reasonsfor poor reasoningperformance unclear;definitive conclusions cannotbe drawn

R, S

Aithal, V. (2006) To assess utility of masking leveldifference (MLD) as a measure todetect hearing loss in Aboriginalstudents with OM history

Aboriginal children showedlower MLD than control group.Auditory processing disorders(APDs) related to early auditorydeprivation may havesignificant adverse effects onschool performance.

MLD a less culturally biased measure andmore easily administered than manyspeech and language test procedures.

Comparison group, use of MLD Sampling not described;uneven groups

S

Nelson, A(2007, 2004)

To investigate what constitutes asocially and culturally appropriateOT service for urban IndigenousAustralian families in Brisbane

Service provision in context ofschool favorably; need todevelop effective relationshipsand qualities; understanddifferent backgrounds of clientand therapist; address logisticalissues of service delivery

OTs may need to make changes to theway in which they organize and deliverservices to Indigenous clients.

parents included in sample;majority of participantsIndigenous; service coordinatedby Aboriginal health service;multiple informants andmethods; facilitated reflectionof service and practice

limited to 1 service type;children's perspectives notincluded; potential forresponse bias

S

Partington, G.(2006)

To outline effective teachingstrategies to improve literacy andeducation outcomes of Indigenousstudents

A variety of teaching strategiesand environment likely to assistin improving educationaloutcomes

Teachers and their schools were importantfactors in improving educational outcomes

theoretical sampling ofsuccessful teachers enabledfocus on key characteristics,practices

potential for socialdesirability; no description ofsampling, recruitment,response rate; theoreticalsampling potentially narrow

S, I

English as a second language (ESL); Otitis Media (OM); Aboriginal Medical Service (AMS); Ears, nose, and throat (ENT); masking level difference (MLD); Auditory processing disorders (APDs); Occupational therapists(OTs); kilometer (km); Category: (R-recognition/awareness; A-Access; S-Solutions; I-Intervention; Q-Sequelae/outcomes); Level of Evidence: I Evidence from a systematic review, meta-analysis of all relevant randomizedcontrol trials (RCT) (Strongest); II Evidence from at least one well-designed RCT; III Evidence from well-designed controlled trials without randomization; IV Evidence from well-designed case–control and cohort studies;V Evidence from systematic reviews of descriptive and qualitative studies; VI Evidence from single descriptive or qualitative study; VII Evidence from the opinion of authorities or expert committee reports (Weakest).

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Table 2 Intervention studies

First Author(year)


Design Aims Level ofEvidence

TRENDScores

Population GeographicSetting

Intervention type Methods

Ryan, B.(2006)

Hearing Experiment;intervention

To investigate IndigenousAustralian children's attitudesof peers wearing hearing aids

VI 13 60 Indigenous Australianchildren aged 5–12 years(mean age 9)

3 urban schools inAlice Springs

learning- baseddesensitizationprogram

Experiment (photographs of Aboriginalpeople with and without hearing aids,attitudes surveyed, 20 min. educationalintervention on benefits of hearing aids)

Strange, A.(2008)

Hearing Experimental;intervention

Identify the negative stigmasattached to hearing aids,increase awareness ofattitudes

VI 13 62 Indigenous adolescentsboarding at high schoolsAlice Springs aged 12–18(mean age 14)

Alice Springs learning- baseddesensitizationprogram

Experiment (photographs of Aboriginalpeople with and without hearing aids,attitudes surveyed, 20 min. educationalintervention on benefits of hearing aids)

Yonovitz, L.(2000)

Hearing Intervention Demonstrate link betweenhearing loss and low Englishliteracy

VI 10.75 1,032 Indigenous students4–22 years old representing106 rural and remotecommunities

NT (Darwin andAlice Springs)

phonologicalawareness

Teacher in-service sessions; pre/post PA-EFL criterion- referenced, diagnostic tests

Massie, R.(2004)

Hearing Intervention Identify effects of sound-fieldamplification oncommunication inclassrooms of Aboriginal andTorres Strait Islander children

VI 11 64 Aboriginal and TorresStrait Islander studentsfrom 4 classrooms in tworural QLD schools

Rural QLDcommunities

amplification trial Classroom observation; teacherquestionnaire; assessments, modifiedEnvironmental Communication Profile,Screening Identification for TargetingEducational Risk rating scale

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Table 2 Intervention studies (Continued)

First Author(year)

Indigenousinvolvement

Recruitment Controlgroup

Language Content/components Duration Evaluation Key Findings Conclusions/recommendations

Category

Ryan, B.(2006)

CommunityConsult

No info Reverseordered

English andTiwi

discussion-basedintervention was designedto encourage theparticipants to reducestigma and negativeattitudes towards peoplewho wear hearing aids;demonstrations; An audioexample; scenarios

10minutes

Survey Children had negativeattitudes towards otherswith hearing aids;intervention had significanteffect on attitudes

Children had more negativeattitude towards peers withhearing aids; intervention hadsignificant effect on attitudes;Potential for negative attitudestowards peers w/hearing aidsto be changed via learning-based discussion aimed atreducing negative attitudes.

A

Strange, A.(2008)

CommunityConsult

No info Reverseordered

English andTiwi

discussion-basedintervention was designedto encourage theparticipants to reducestigma and negativeattitudes towards peoplewho wear hearing aids;demonstrations; An audioexample; scenarios

20-30minutes

Survey greater visibility of thehearing aid, is associatedwith more negativeattitudes by adolescents;intervention demonstratedsome reduced stigma

Stigma and negative attitudescontribute to the low use ofhearing aids in children; Needto develop appropriatestrategies to decrease stigmaand increase the use ofamplification; appropriateattitude changing techniquesinterventions needed

A

Yonovitz, L.(2000)

Not reported No info None English 1)two-day workshops foreach school for teachersand assistant; 2)provision ofamplification systems andhearing aids; 3) ear,hearing, phonologicalawareness assessment; 4)reading, spellingassessment; (over 1 schoolyear)

12 months ear, hearing,phonologicalawareness, reading,and spellingassessments

Teacher training, hearingsupport services, screening,and phonologicalawareness interventiondocumented strongimprovements in literacyand contributed tounderstanding relationshipbetween ear disease andlow literacy.

This intervention represents afeasible, adaptive program thatcan be used in combinationwith existing ESL curricula andshould not cause interferencewith already published phonicsprograms.

S, I

Massie, R.(2004)

Nonereported

No info None English amplification on/offconditions changedfortnightly

8 weeks Teacher survey,sensoryassessments

Sound-field amplificationintervention encouragedthe children to interactwith teachers and peers ina proactive way.

No clear or enforceablestandards for classroomacoustics in Australia exist;amplification may providerapid, cost effective part ofsolution to improving theclassroom listeningenvironment.

S, I

Queensland (QLD); Category: (R-recognition/awareness; A-Access; S-Solutions; I-Intervention; Q-Sequelae/outcomes); Level of Evidence: I Evidence from a systematic review, meta-analysis of all relevant randomizedcontrol trials (RCT) (Strongest); II Evidence from at least one well-designed RCT; III Evidence from well-designed controlled trials without randomization; IV Evidence from well-designed case–control and cohort studies;V Evidence from systematic reviews of descriptive and qualitative studies; VI Evidence from single descriptive or qualitative study; VII Evidence from the opinion of authorities or expert committee reports (Weakest).

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Table 3 Discussion papers

FirstAuthor(year)


Design Level ofEvidence

Population Setting Aims Key Findings Conclusions/recommendations Category

de Plevitz,L. (2006)

GeneralDisability

Discussionpaper; policyanalysis

VII Antidiscriminationlaw versus criteriafor Indigenousstudents sent tospecial schooling

Australia To argue that criteriadeveloped for theallocation to specialschooling may constituteindirect racialdiscrimination againstIndigenous students

Education authorities could beliable despite unintentionaleffects; need for classallocation assessment byIndigenous educators.

National standards could bedeveloped against which thereasons for placing students inspecial classes could be tested fortheir reliance on embeddedcultural expectations andassumptions; need for thecollection of national data onspecial schooling.

A

Gilroy, J.(2010)

GeneralDisability

Policy analysis VI Policy documentspublished 1985-2010

Australia To analyze how NewSouth Walesgovernment-administered disabilityservices positions andrepresents Aboriginalpeople with disability

Aboriginal people withdisability were specialized fieldwithin the mainstream servicesystem - 'cultural difference','remoteness' and'vulnerability', but never apolitical group

The concept Aboriginal peoplewith disability is a 'label' thatconceptualizes what is not anormal person with a disability.

A

Cornish, D.(2011)

Hearing Discussionpaper

VII Aboriginalchildren

Australia To discuss link betweenhearing disability inAboriginal children,language acquisition, andschool performance

Reference to 2010 federalSenate inquiry into Indigenousear health

Need to improve classroomacoustics in existing schools;police, courts and prisons providemore support for the hearingimpaired

Q

Howard, D.(1992)

Hearing Discussionpaper/Tool

VII Aboriginalchildren

Australia To describe a hearingassessment feasible forschool use.

Identification of Aboriginalchildren's hearing loss isimportant because of themajor educational and socialconsequences of conductivehearing loss.

Aboriginal children's hearing loss isoften not identified, in partbecause of 'masking' due tocultural differences. Simple speechreception game is effective inidentifying children with hearingloss (for use by parents andteachers).

R, S

Henderson,I. (1993)

Hearing observation;personalcommunication

VI Aboriginalcommunities

North QLD &WAAboriginalcommunities

To explore mismatchbetween remoteAboriginal concepts ofdisability and urban non-Aboriginal institutions

Remote area Aboriginalpeople have unique conceptsof disability, hearing loss andotitis media

Consideration of variations inconceptualizations of disability isnecessary in developing solutions

R

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Table 4 Literature reviewsFirstAuthor(year)


Methoddescription

Population Setting Aims Key Findings Conclusions/recommendations Category

Thorley, M.(2011)

Intellectualdisability;general

No Primaryschool- agedIndigenousAustralianchildren

Australia To present OTs with practice guidelinesfor conducting assessments with thispopulation

Casual discussion with the client ispreferable to a formal initial interview;Having Indigenous health workerpresent is appropriate andrecommended

There is a general lack of research onassessments for Indigenous children;When working with Indigenouschildren: time should be invested inestablishing relationship; familiarenvironment enabling therapist to buildrapport; communication strategiesincluding softer voice, avoiding jargon,using demonstration for unfamiliartasks, using non-verbal media.

A, S

Williams, C.(2009)

Hearing No Indigenousand non-indigenouschildren

Australia To discuss increased risk of negativecognitive and educational sequelae inIndigenous children with OM

Indigenous children may be at higherrisk of cognitive and educationalsequelae; early onset, more frequentinfections, and infections of longerduration shown to be risk factors forlong-term consequences.

Need for approaches to otitis media inIndigenous population that encompassboth medical and educationalconsiderations.

Q

Tourky, A.(1992)

Vision No Aboriginalchildren

Remote andisolatedcommunities

To analyze the significance and the roleplayed by the teachers in educating theAboriginal children with visualimpairments

Children with mild, moderate or severevisual problems develop behaviors(limited persistence due to fatigue,frustration with task completion orrefusal to commence tasks, decreasedmotivation) that have negative effecton learning and school and non-schooltasks.

Behaviors due to the visual problemshave extremely significant negativeimpact on learning; measures neededto reduce adverse impacts.

Q

O'Neil, M.(2004)

Generaldisability

nodescriptionof searchterms,timeframe

Australianliterature

Australia To identify unique issues confrontingIndigenous people with disabilities,their families, & communities

Indigenous people with a disability aregenerally not excluded from orstigmatized in their communities;disability may be viewed as a family orcommunity problem, rather than apersonal one

Little is known about the actual burdenof disability experienced by Indigenouspeople, no firm data about the extentto which the use of disability supportservices by Indigenous people reflectstheir burden of disability.

R

Gunasekera,H.( 2009)

Hearing Yes OMmanagementliterature

Australia To summarize best evidence formanagement of OM

Indigenous children with AOM shouldbe treated with antibiotics on first visit;children with OME, and no speech andlanguage delays, can be observedsafely for 3–6 months; children withCSOM need ear cleaning & topicalantibiotics.

HPs managing these children can usethis evidence to make informeddecisions and can discuss the pros andcons of the different managementoptions with the child’s parents/carers

S

Burrowet al. (2009)

Hearing-strictly

No Educationalapproaches

Australia impact of hearing loss; factorscontributing to hearing loss; preventionand management of otitis media andhearing loss; education strategiesaddressing hearing loss; and policiesand policy implications for reducinghearing loss and its educationalconsequences.

Summaries of hearing-relatedscreening, diagnosis, treatment,rehabilitation, language, amplification,and management issues.

Little government and policy supportfor research on education, social,emotional, family and communityeffects of Indigenous hearing loss.

R, A, S, I,Q

Otitis Media (OM); Chronic Suppurative Otitis Media (CSOM); otitis media with effusion (OME); acute otitis media (AOM); Category: (R-recognition/awareness; A-Access; S-Solutions; I-Intervention; Q-Sequelae/outcomes).

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Table 5 Grey literature reports

Citation Design Level ofEvidence

Focus/Setting Key Findings Key Strategies

Owen, L., M. Gordon, et al. (2002).Listen to us - supporting families withchildren with disabilities: identifyingservice responses that impact on therisk of family breakdown. The FamilyResilience Project; Melbourne, Vic,Disability Services Division, Departmentof Human Services.

1 focus group withAboriginal families

V Examination of services to supportfamilies with children with disabilities/Vic

Support groups reported useful byparents; essential elements includeaccessibility, and common interestbased on either location, Aboriginal orethnic community bonds, or on thedisabling condition of the child; livingin rural/ remote areas, being membersof Aboriginal communities, or ofculturally and linguistically diversecommunities, being on low incomes orbeing socially isolated, can haveimplications for what and how supportis provided

Best practice elements - ProactivePrevention and Early Intervention;empowerment; continuity,comprehensiveness; flexibility,strengths-based, partnership, expert,culturally sensitive, promotion andprotection of rights, family and child-Focused and responsive, long-term,seamless and integrated, accountability.

Couzos, S., T. Lea, et al. (2003). NACCHOear trial and school attendance project.Deakin, ACT, Deakin, ACT: NationalAboriginal Community ControlledHealth Organisation, 2003.

Aboriginalcommunity-controlled multi-center double-blindrandomizedcontrolled clinical eartrial (N = 147)

II Impact of CSOM and treatment onschool attendance of Aboriginalchildren/WA and QLD

High level of significant hearingdisability among Indigenous Australianstudents; associated with learningdisability, school absenteeism.

Schools should more effectivelyengage with health sector.

Telethon Institute for Child HealthResearch (2004). The health ofAboriginal children and young people:summary booklet. West Perth, WA,Telethon Institute for Child HealthResearch.

Survey (N = 5,289) IV Investigation of health of Indigenouschildren to inform preventativestrategies promoting healthydevelopment and well-being/WA

27% of children were limited in one ormore sensory functions (vision, hearingor speech) or experienced pain.

Highlights the need for action acrossand beyond health sector to addressthe complex and inter-related factorsthat contribute to the increased risk ofhealth problems amongst Aboriginalchildren.

Aboriginal Disability Network NewSouth Wales. (2007). Telling it like it is: areport on community consultationswith Aboriginal people with disabilityand their associates throughout NSW,2004–2005. Sydney, Sydney: AboriginalDisability Network New South Wales,2007.

Communityconsultations

V Report of community consultationsthroughout NSW during 2004/2005with Aboriginal people with disabilityand their associates (not child-specific)/NSW

Under-representation of Aboriginalpeople with disability social, health,community, and disability services,related to policy and structural failures.Concerned over undiagnosedunassisted cases leading to schoolexpulsion. High use of out-of-homecare environment due to lack ofawareness of support, culturallyinappropriate support, fear of asking forhelp, lack of resources, postponinghelp-seeking until crisis, family andcommunity problems.

Government and non-governmentservice providers need to developrelationships with Aboriginalcommunities that are based on trustand equitable partnerships;Recognition of need for moreresources to be able to meet theneeds of Aboriginal owned andoperated services; A focus upon earlyintervention programs; Prevalencestudies needed Aboriginalcommunities nationwide

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Table 5 Grey literature reports (Continued)

Snodgrass F., G. Groves, et al. (2007).Aboriginal students with disabilities:otitis media and conductive hearingloss. Adelaide, Adelaide: MinisterialAdvisory Committee: Students withDisabilities, 2007.

case study, interviewswith government,non- government,health professionals

V Study on Aboriginal children (andfamilies) with or at risk of developingotitis media and conductive hearingloss/SA

Perceived lack of referrals for Aboriginalchildren to early intervention programs;lack of relevant resources for Aboriginalfamilies targeting ear health; ESL andaccess considerations; staff turnoveraffects relationships; Aboriginal healthorganizations limited in time andresources to provide communityeducation; inconsistent informationprovision; difficulty accessing Aboriginalfamilies with children under the age of3; skilled workforce required(audiometry, teaching); schoolresistance to sound amplificationsystems.

Increase awareness and understandingamongst Aboriginal families of causes,consequences, treatments of ear/hearing health; improve preschool andschool based education of hearinghealth and Aboriginal children's needs;service agreements between healthservices, including Aboriginal healthteams and community groups, andeducation sectors

Calma T. Preventing Crime andPromoting Rights for Indigenous YoungPeople with Cognitive Disabilities andMental Health Issues, Australian HumanRights Commission, Sydney, March2008

communityconsultations; casestudies

V Investigation of early intervention anddiversionary practices aimed atpreventing offending behavior inIndigenous young people with acognitive disability and/or a mentalhealth problem/Australia-wide

Young people with cognitivedisabilities or mental health issues fallthrough the cracks of communitysocial services and end up in custody;clear evidence linking low educationalachievement to involvement incriminal justice system. Cultural bias intesting; inaccurate identification ofIndigenous children as havingcognitive disabilities; early identificationand early intervention opportunitiesmissed.

Correct assessment and diagnosis of acognitive disability; early interventionprograms targeting multiple risks;holistic and participative approach tosolution development andimplementation; early interventionresearch needed to tailor theseprograms to meet the needs ofIndigenous peoples.

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teachers. Cultural considerations in behaviour, language,and conceptual differences are critical in appropriatelyidentifying, assessing, and managing hearing loss andother disability in young Indigenous children at school[37]. Greater access to Indigenous teaching staff and In-digenous Education Workers in schools will facilitateculturally appropriate support for Indigenous students[37,38]. Professional development and cultural compe-tence training for non-Indigenous teachers, including in-formation about hearing loss, effective cross-culturalcommunication strategies, behaviour management strat-egies [38], and possible behavioural indicators of Indi-genous children’s hearing loss [39] will contribute toIndigenous children’s school experiences as well. On-going training of Aboriginal community audiometriststo provide community, school, and preschool (includinginfants) screening programs are additional ways toaddress these issues [27].

Barriers to service accessO’Neill [32] reported that factors contributing to Indi-genous use or non-use of disability support servicesare complex, and involve perceptions of attitudes,understandings and values regarding disability, languagebarriers, poor coordination between services and levelsof government, workforce issues, racism among serviceproviders, and socioeconomic disadvantage, includinghousing and transportation.Access to services is often limited in remote areas [37].

Gunasekera found that rural and remote areas managedmore cases per week than their urban counterparts, buthad less access to specialist audiology services [40]. Urban-dwelling does not guarantee timely access to criticalservices, however. Although 20% of rural/remote Indigen-ous children wait longer to see audiology services fortesting than the guideline recommended 3 months, one ineight Indigenous children nationwide wait longer thanrecommended for ears, nose and throat services. Theseresults indicate that delays between presentation and treat-ment may be more widespread than what is generallyperceived [40]. Government-funded hearing services, inparticular, have been depicted as not meeting the needs ofIndigenous people [37].

Potential solutions – ways of working with Indigenousfamilies and childrenInvolvement of the family in bi-cultural education wassuggested as a facilitator of family engagement in pri-mary health prevention and treatment [41]. In regards toworking with health and service providers, families pre-ferred to build a relationship over time, opportunitiesfor discussion, and an emphasis on the abilities of thechild rather than the disability [19].

Recommendations for mitigating hearing loss in schoolsinclude phonological awareness programs and hearingsupport services which have demonstrated improvementsin literacy levels [42,43]. Use of classroom-wide soundfield amplification has been found to encourage children’sinteraction with teachers and peers [44]. Importantly,amplification may reduce stigma and negative attitudes ofpeers which have been found to inhibit hearing aide use[45,46]. Although this appears to be a rapid, cost effectivepart of the solution, there are no clear or enforceablestandards for classroom acoustics in Australia [44].Although not delineating specific disabilities, three

articles were identified that centred on developingand maintaining relationships between allied healthprofessionals, young Indigenous children and families,and teachers. Facilitators to successful occupational ther-apy access included investing and committing time toestablish and maintain therapeutic relationships andusing appropriate communications strategies such asgaining and giving knowledge with a respectful tone,using understandable language, and demonstrating un-familiar tasks [47]. Additional facilitators include settingthe program in culturally safe and accessible locations,such as an Indigenous health or educational setting, andinvolving Indigenous health workers [47-49].

Gap in research – the familyOverall, the voices and needs of Indigenous families ofchildren with disabilities were minimally representedin the literature identified. It was noted that teachers’reports of behavioural issues reflective of unidentifiedhearing impairment, for example, can impact on thefamily negatively [37]. One report specifically targetingIndigenous families of children with disabilities indicatedthat families wanted practical support such as transportto multiple appointments and completing forms.

DiscussionWith one of the highest rates of OM in the world, it is notsurprising that a preponderance of literature on AustralianIndigenous child health depicts the implications of thispreventable and treatable disease. Despite disabilitymanifesting in low rates of school participation and reci-divism, there are minimal data on Indigenous childhoodand disability [50], as has been reported in other Indige-nous populations [16]. This was apparent in the currentreview as well as in a recent analysis of descriptive studiesdescribing the health, development, wellbeing of Indigen-ous children which found that research predominantlyaddressed physical health (75.1%), health determinants(27.6%), and mental health and wellbeing (2.8%) [50]. Theresurgence in the literature is evident in adolescencewhere drug, alcohol, and incarceration manifest as evi-dence of marginalisation, racism, and a failure to address


early childhood disabilities, many of which are treatablewith early intervention [51].Despite 53% of the Indigenous population living in

major cities or inner regional areas of Australia [52],the literature predominantly focused on rural/remote-dwelling populations [50]. Likewise omitted from theextant knowledge, particularly in peer-reviewed forums,are the experiences of the Indigenous family, carers, andchildren and their unmet needs. This is an importantfocus for future research.

Factors impacting prevention, recognition, and accessThe higher rate of disability in Indigenous compared tonon-Indigenous Australians is a pattern of disparity seenin many Indigenous populations throughout the world[16]. Socioeconomic disadvantage has been linked to in-tellectual and developmental disability, both as causeand effect, given inequitable resource allocation withinsocial systems and subsequent contextual issues [53].Socioeconomic disadvantage, racism, and oppression in-fluence learning and health outcomes [16]. The absenceof Indigenous Australian child disability statistics until2006 reflects this history of dispossession, distrust, andenduring disparity. The legacy of stolen generationsand a recent resurgence of government control [54] hasresulted in a strong scepticism and mistrust of govern-ment organisations.Considerations for addressing disability in Indigenous

children are depicted in Figure 2. Differences between Indi-genous and non-Indigenous people’s conceptualisations ofdisability, impairment, and behaviours may impact onidentification or diagnosis of a disability, an important steptowards early intervention that can improve a child’s social,language, and communication development and contributeto school readiness [16]. As noted in the Australian litera-ture, systematic screening for delay or impairment, particu-larly where English is not the first language, is vital [16].The significant and enduring consequences of unad-

dressed disability were discussed and suggestions for im-proving awareness of cultural differences in educationsettings and tailoring programs to address the needs of In-digenous children provided. Johnston [55] has describededucation as positively associated with health through me-diating pathways that exist at individual, family and com-munity level. Johnston [55] urges clinicians to considerearly childhood and school education as an importantfocus that requires rigorous research into interventionsthat address the barriers to effectiveness in implementingquality educational experiences and opportunities for Indi-genous children.There are a number of strategic initiatives to address

the data shortcomings, to date, and to address factorsthat will maximise Indigenous participation in society.Among these is the Study of Environment on Indigenous

Resilience and Child Health (SEARCH) project, a pro-spective longitudinal cohort study which will be a long-term resource to investigate the causes and trajectoriesof health and illness in Indigenous children aged 0–17from urban and large regional centres in New SouthWales, Australia, to identify potential targets for inter-ventions to improve health. Data is being collected onOM, hearing impairment, and developmental delay [56].Another example is the Gudaga study, a prospective de-scriptive longitudinal cohort study assessing the health,development, and service use of Indigenous infants andtheir mothers in Southwest Sydney [15]. The work ofthe Telethon Institute for Child Health Research is alsoproviding a stimulus for addressing the health and well-being of Indigenous children [57].

Strengths and limitationsThis review was limited by the available published litera-ture and therefore does not reflect the scope of theproblem. Although government reports and othersources of the grey literature were reviewed for thisproject, sparse data reflects that many issues of child-hood disability hover below the radar and only manifestwhen the consequences are dire and catastrophic [58].Although a feature of disability [58], this is likelyaggravated among Indigenous children where a disclos-ure of a problem may cast an unwanted focus on familycircumstances and social situation.Given that the needs of these populations are very

unique, the outcomes of the retrieved studies may not begeneralisable to the entire Australian Indigenous nor otherIndigenous populations, necessarily. This review wasundertaken using rigorous methods and has identified po-tential solutions for addressing childhood disability. Thisreview has elucidated important contextual determi-nants of child health and disparities among IndigenousAustralians. It also underscores the importance of shiftingfrom a purely biomedical lens to a holistic approach to ad-dress the needs of vulnerable Indigenous children. Thiswill require ongoing partnership and collaboration be-tween health, education, and social service agencies.Given the diverse study designs and inconsistent

reporting, the ability of this review to decipher strength ofevidence was limited. Instead, this review has provided asnapshot of the current foci of literature and approachesto describing disability in Australian Indigenous children.

A way forwardThe solutions for addressing health disparities andmaximising societal participation among IndigenousAustralians have been clearly identified by Indigenouspeople. Recognising and addressing entrenched and in-stitutional racism is an important first step in ensuringthe needs of Indigenous children are addressed [59].

Issues affecting awareness & recognition

• Screening

• Perceptions of disability

• Stigma

• Social determinants

• Cultural differences

Issues affecting access to support

• Cultural competence of service

• Racism, marginalization

• Socioeconomic disadvantage

• Availability & waitlists

• Geographic distance

• Differential management

• Stigma

Addressing social

determinants

Involvement of Aboriginal

Health Workers

Workforce enhancement

in health & education

Culturally Appropriate

Services

Family & community involvement

Solutions

Figure 2 Considerations in dealing with disability in Aboriginal children.


This review has indicated that a great deal is still un-known about Indigenous childhood disability, yet im-portant foci should include prevention of problems thatimprove health and living situations, particularly effect-ive antenatal care. Importantly, factors that promote pre-vention, recognition, access, and viable solutions, assummarised in Figure 2, are warranted.Further research must be conducted in order to provide

evidence for effective and sustainable practice and policy.This is particularly the case for developing culturally appro-priate interventions. Ensuring such research is led by Indi-genous people using appropriate methods is a critical stepin developing tailored and targeted solutions. It is criticalthat health and social services are accessible and accept-able to Indigenous people. Indigenous-led and controlledservices are an important form of engagement. Increasingthe workforce participation of Indigenous people in health,education, and social services [60] is an important step andstrongly linked to addressing childhood disability andmaximising participation in the education system [38].Achieving these goals requires addressing entrenched

power relationships and dismantling barriers betweenmainstream and Indigenous controlled services. It alsowill require challenging traditional professional boundar-ies and decreasing silos between health, education, andsocial services. Given the links between childhood dis-ability and education, teachers have an essential role to

play in monitoring developmental stages, thus necessi-tating teacher training that ensures appropriate recogni-tion of potential disability. Greater congruency betweenhealth and education systems needs to occur, as well asother strategies to ensure children with hearing disabil-ities are not left behind, such as amplification systemswith classrooms [61].

ConclusionsDespite higher rates of disability than in non-Indigenouschildren, this review has identified the scant focus on dis-ability in Indigenous children in the face of the burdenand ramifications of not achieving educational and socialmilestones. Given the lack of research in this area, furtherinvestigation must be conducted. The emphasis on OM inthis review reflects the hard work of a committed group ofresearchers, but currently, the literature fails to encapsu-late the breadth and complexity of Indigenous childhooddisability. Although extensive investment is apparent indownstream health problems, ensuring the foundations ofhealth and wellbeing through early intervention is criticalin decreasing health inequity.

AbbreviationsWA: Western Australia; CINAHL: Cumulative Index to Nursing and AlliedHealth Literature; APAIS-ATSIS: Indigenous Australia, Australian Public AffairsInformation Service-Aboriginal and Torres Strait Islander;ATSIHealth: Aboriginal and Torres Strait Islander Health; ERIC: Education


Resources Information Center; MeSH: Medical Subject Headings;STROBE: STrengthening the Reporting of OBservational studies inEpidemiology; TREND: Transparent Reporting of Evaluations withNonrandomized Designs; OM: Otitis Media; SEARCH: Study of Environmenton Indigenous Resilience and Child Health.

Competing interestsThe author(s) declare that they have no competing interests.

Authors’ contributionsMD contributed to conception and design, acquisition and analysis of data,and manuscript drafting and revision. PMD contributed to conception anddesign, acquisition and analysis of data, and manuscript drafting. TDacquired and analysed data and revised the manuscript. SJM contributed todata analysis and manuscript drafting. PD contributed to study conception,design, and review. PA contributed to conception, design, and manuscriptrevision. JD contributed to study conception and review. FV contributed tostudy conception and review. All authors read and approved the manuscript.

AcknowledgementsPD, PA, JD, and FV acknowledge funding support from the Commonwealthof Australia, Department of Ageing, Disability, and Home Care. PMD and MDacknowledge the funding support of the University of Technology Sydneyand the National Health and Medical Research Council Capacity BuildingGrant (533547). MD is a postdoctoral fellow supported by this grant. PMD,MD, PD, PA, JD, and FV acknowledge the funding support of the AustralianResearch Council (LP120200484).

Author details1Centre for Cardiovascular and Chronic Care; Faculty of Health, University ofTechnology Sydney, PO Box 123, Broadway, NSW 2007, Australia. 2CurtinUniversity, Curtin Health Innovation Research Institute, Perth 6845, Australia.3Aboriginal Medical Service Western Sydney, PO Box 3160, Mt Druitt, NSW2770, Australia. 4University of Western Sydney, Penrith, New South Wales1797, Australia.

Received: 13 April 2012 Accepted: 15 January 2013Published: 18 January 2013

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doi:10.1186/1475-9276-12-7Cite this article as: DiGiacomo et al.: Childhood disability in Aboriginaland Torres Strait Islander peoples: a literature review. InternationalJournal for Equity in Health 2013 12:7.

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