Download Outcomes of Children with Hearing Loss a study of children

Supported by NIDCD R01 DC009560
Mary Pat Moeller
Bruce Tomblin
Melody Harrison
Sophie Ambrose
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Study Description and
Demographics
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Background
• Most outcome studies to date focus on children
who are deaf
• Reduced body of literature concerning children
with mild to severe HL
–
–
–
–
Sample sizes are small or mix D/HH children
Lack of control of amplification histories/audibility
Few studies attempted a population sample
Varied measurement strategies; earlier generation
technologies
• Need to understand sources of individual
difference in outcomes
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Aims of Study
• To describe the characteristics of:
– children and families
– intervention services
– factors associated with service variations
• To characterize:
– developmental, behavioral and familial outcomes
– compared to normally-hearing age mates with similar
backgrounds
• To explore:
– how variations in child and family factors and in
intervention characteristics relate to functional
outcomes
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Sources of Data
•
•
On Site Testing of Children with Families Completing Questionnaires
Telephone Survey of Parents
•
•
•
Audiology Service Provider Survey (online)
Services & Provider Survey (online)
•
•
•
•
Birth to Three
Pre-School
School Age
Teacher Survey
•
•
•
One person will be administering a questionnaire
concerning home and parental information
Pre-School
School Age
Medical Records
•
ENT & Pediatrician
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Study Design
6
Accelerated Longitudinal Design
• Each child followed for 3 years+.
• Retrospective data prior to enrollment obtained by
medical record history.
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Domains of study
7
Speech
Production
Language
Skills
Psychosocial
and
Behavioral
Hearing &
Speech
Perception
Background
characteristics
of
child/family
American Speech-Language Hearing Association, 2011
Academic
Abilities
Child and
Family
Outcomes
Interventions
(clinical, educ
ational, audio
logical)
Outcomes of Children with Hearing Loss
Inclusion Criteria
•
•
•
•
Ages 6 months to 6 years 11 months
English is spoken in the home
No major secondary disabilities
Permanent Mild to Severe Hearing Loss
– PTA of 25-75 dB HL (500, 1k, 2k, 4 kHz)
• Goals
– 400 children with hearing loss
– 150 children with normal hearing
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Participants
Centers
HH
NH
Boys Town
117
40
85
48
North
Carolina
104
24
Total
306
112
Iowa
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Maternal Education
45
40
35
Percent
30
25
20
2010 Census
15
HH Mothers
10
NH Mothers
5
0
Less than
HS
HS
Post
Secondary
College
Degree
Graduate
Ed.
Educational Level
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Distribution of Children with Hearing Loss
Tested at Each Age Level
60
N
u
m
b
e
r
50
40
30
20
10
0
0.5
1
1.5
American Speech-Language Hearing Association, 2011
2
3
4
Protocol Administered
(Age Level)
5
6
7
Outcomes of Children with Hearing Loss
Distribution of Better Ear Pure Tone Averages
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Age at Hearing Aid Fitting
120
100
100
80
60
40
20
32
13
8
11
7
10
4
15
0
Age at HA Fit
(Months)
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Maternal Education and Age of Confirmation
and Hearing Aid Fitting
Mean
18
18
16
16
14
14
12
12
10
10
Age of confirmation
8
Aid Fitted
6
Difference between
confirmation and fitting
4
2
0
American Speech-Language Hearing Association, 2011
Age of confirmation
8
Aid Fitted
6
4
Months
Months
Median
Difference between
confirmation and fitting
2
0
Outcomes of Children with Hearing Loss
Meeting the Goals Established by JCIH
80
70
60
50
40
30
20
10
0
1st diagnostic by 3
mos (.25-55)
Confirmation by 3
months (.5-60)
American Speech-Language Hearing Association, 2011
HA fit by 6 mos (262)
EI entry by 6 mos, (057) (n=159)
Outcomes of Children with Hearing Loss
Projected Enrollment Status
OCHL future status
180
160
140
120
Today
100
Jan of 2012
80
June of 2012
60
Jan of 2013
40
June of 2013
20
Jan of 2014
0
6
12
18
month month
2 year
month
3 year
American Speech-Language Hearing Association, 2011
4 year
5 year
6 year
7 year
8 year
9 year
10 year
Outcomes of Children with Hearing Loss
Speech Production
Pragmatics
Basic
Speech Syntax Concepts
x
x
x
x
5
American Speech-Language Hearing Association, 2011
70
85
100
115
130
Outcomes of Children with Hearing Loss
14
Speech Production and Hearing Loss
• Delays in babble onset increase with increasing
hearing loss (Carney, 1996)
• Some children at risk for slow transitions from
babble to word productions (Moeller, et al., 2007)
• Delays in use of fricative class (McGowan, et
al, 2008; Moeller, et.al, 2007)
• Generally intelligible speech as they mature
(Wallace, et al, 2000)
– Number & type of phoneme errors increase with
increased severity of loss (Elfenbein, et al, 1994)
– Substitution of fricatives & affricates most common
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Speech Production: Measures
1. Vocal Development Landmarks Interview
2. Open and Closed Set Test (O&C)
3. Conditioned Assessment of Speech
Production (CASP)
4. Goldman Fristoe Test of Articulation –
Second Edition (GFTA-2)
5. Beginner’s Intelligibility Test (BIT)
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Vocal Interview
• Moeller & Bass-Ringdahl, OCHL Project
• Age: 6-24 months
• Parent interview regarding child’s achievement of
vocal landmarks
• Uses power point slides and audio files to provide
parents with examples and paired comparisons of
vocal behaviors
• Advantages:
– avoids use of technical terms
– ensures that parent and clinician are “on the same page”
– calibrates examiners
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Vocal Interview: Item 2-2 (canonical)
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Vocal Interview: Cross-Sectional
ps < .01
80
Percent Score
70
60
Hard of Hearing
50
6 month (n=16)
12 month (n=29)
18 month (n=29)
40
30
20
10
0
Precanonical
Canonical
American Speech-Language Hearing Association, 2011
Word
Total Score
Outcomes of Children with Hearing Loss
Open & Closed Set Test (O&C)
•
•
•
•
•
A measure of perception-production
Appropriate for approximately 18 to 24 months
Developed by Ertmer, Miller, & Quesenberry, 2004
10 items, realistic pictures
Prompted production followed by picture identification
KEYS
[email protected]
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
O&C: Administration
Mom: And “keys”….Child: /tis/…Mom: uhhuh, where are they?
Child: /tis/ + point. Mom: very good
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
O&C: 2 Year Old Results
ps < .01
Percent Correct
120
100
80
60
NH, n=29
HH, n=75
40
20
0
Phonemes
Matched
Word
Acceptability
American Speech-Language Hearing Association, 2011
Comprehension
Outcomes of Children with Hearing Loss
Conditioned Assessment of Speech Production (CASP)
• Parent and examiner work together to
prompt the child to imitate:
– Three canonical forms (e.g., /i/ /i/ /i/)
– Five canonical forms (e.g., /ma/)
– Two advanced forms (e.g., /tʌk/
• Imitations are given a score of 0, 1, or 2
based on acceptability criteria
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
CASP: Administration
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
CASP: 2 Year Old Results
p < .001
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
GFTA-2: Cross-Sectional Data
140
Standard Score
120
p = .002
n=29
n=75
p < .001
n=23
n=75
p = .018
n=15
n=36
100
80
60
NH
40
HH
20
0
3 years
5 years
7 years
Ages
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
GFTA-2: Relationships with Hearing
n = 151
140
GFTA Standard Score
120
100
80
60
40
20
0
0
20
40
60
Better Ear PTA
r = -.258
p = .001
80
100 0
0.2
0.4
0.6
BESII
r = .360
p < .001
0.8
1
BEPTA and BESII: r = -.843, p < .001
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Beginner’s Intelligibility Test (BIT)
• Children are asked to repeat 10 sentences
from one of four lists (e.g., “My car is blue.”)
– For children ages 3;0-4;11, sentences are acted
out with toys.
– For children ages 5+, pictures are provided that
correspond with the sentences.
• The BIT score for each child is the percent of
target words correctly transcribed, averaged
across three listener judges.
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
BIT: Cross-Sectional Data
r = -.466
p = .008
GFTA Error Count
50
45
40
35
30
25
20
15
10
5
0
0
Hard of Hearing
5 year old, n = 24
7 year old, n = 10

10
20
30
40
50
60
BIT Score
70
80
Correlations with BIT:
BEPTA: n = 30, r = -.567, p < .001
SII: n = 34, r = .566, p = .001
American Speech-Language Hearing Association, 2011
90 100
Outcomes of Children with Hearing Loss
Speech Production: Key Points
• Vocal Interview: Advances in
canonical babbling and word
formation from 12 to 18 months.
• O&C and CASPP: Children with HL
significantly delayed on phonology
and word production
• Phonology may be vulnerable until
older ages.
• GFTA: Older children have increased
accuracy, but still large variance.
• BIT: Children demonstrate high
variability in speech intelligibility at
5-years of age, but most approach
ceiling levels of intelligibility by 7years of age.
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Language
*Update on receptive-expressive language skills
*Morphological skills
*Verbal and social reasoning skills
*Narrative Measure
•How are these children performing compared to age-matched peers?
•Are selected aspects of language development “at risk?”
•What are the implications for assessment strategies?
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Vocabulary Skills at 5 and 7 Years (PPVT)
M= 117.54
99.47
p = .001
111.86
97.90
PPVT
p = .003
BEPTA
-.270**
BESII
.414**
PLAI
.734**
Reasoning
GFTA
.444**
**ps < .01
15.4%
<85
American Speech-Language Hearing Association, 2011
22%
<85
Outcomes of Children with Hearing Loss
Vocabulary: Relationships with Hearing
r = -.270, p = .001
r = .414, p = .001
n = 88
n = 117
BEPTA and BESII: r = -.792, p < .001
American Speech-Language Hearing Association, 2011
Parameter
Estimate
t
p-value
BEPTA
.109
.636
.526
BESII
.496
2.897
.005
Outcomes of Children with Hearing Loss
Receptive-Expressive Language (CASL at 4 yr)
140
M = 88.8
120
Standard Score
100
80
NH (n=39)
60
HH (n=95)
40
20
0
Basic Concepts
Syntax
Pragmatics
CASL at Age 4 years
Composite
ps < .002
M age = 49.6 months; M BEPTA (HH) = 50.35 dB HL
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Receptive-Expressive Language (CASL at 6 yr)
140
120
Standard Score
100
80
NH (n= 25)
60
HH (n = 60)
40
20
0
Pragmatics
Syntax
Antonyms
Paragraph Comp
CASL Subtest
ps < .02
M age = 73.26 months; BEPTA (HH) = 48.59
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Morphology Elicitation Task
•
•
•
•
DVD developed for OCHL project
To explore an aspect of language possibly “at risk”
In more detail than typical language measures include
Elicited production of 9 morphological ending types
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Plural elicitation task
Regular Plural
American Speech-Language Hearing Association, 2011
Irregular plural
Outcomes of Children with Hearing Loss
Morphology Elicitation Task: Age 4
120
ps < .05
100
3s = he walks
Percent Correct
80
60
NH (n =36)
40
HH (n = 82
20
Influences?
•Bandwidth
•Phonology
•Sentence position
•Input frequency
0
Mean BEPTA = 49.9 (SD = 15.8); Mean BESII = .75 (SD = .17); Mean Age = 49.3 months
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Verbal Reasoning Skills (age 5 years)
20
PLAI Scaled Score
15
10
NH (n =14)
HH (n = 56)
HH children are
in the average
range on the
Preschool
Language
Assessment
Instrument
but….
5
0
Matching
Selective Analysis
Subtest
American Speech-Language Hearing Association, 2011
Reordering
Reasoning
ps < .05
Outcomes of Children with Hearing Loss
Social Reasoning: Theory of Mind
• Standard False Belief Tasks
• 4 tasks are administered
• Scores range from 0 -4
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Theory of Mind Task Performance (5 years)
NH pass rate = 84%**
HH pass rate = 34%
0.7
Significant
Correlations (HH):
0.6
Proportion of Group
0.5
0.4
NH (n = 25)
0.3
CELF (after
controlling for
vocabulary)
r = .398*, p = .001
HH (n = 88)
BESII:
r = .364*, p =.002
0.2
0.1
0
0
1
2
3
4
BEPTA
r = -.130
Theory of Mind Score (out of 4)
**Chi square = 19.58; p = .001
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Narrative Elicitation: Candy Stealing Story
• Developed by Peter de Villiers
• Obligates : mental terms, reference specification & temporal cohesion
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Narrative Procedure (7+ years)
•Transcript created in SALT
•Scoring Rubric adapted from
Narrative Scoring Scheme
(Miller, et al., 2004)
Child views
slides of
story
Child tells
spontaneous
story to go
with pictures
Clinician tells
scripted
story
American Speech-Language Hearing Association, 2011
Child retells
the story
MEASURES
Introduction
Character
Development
Mental States
Referencing
Conflict/Resolution
Cohesion
Conclusion
Subordination Index
NDW
MLU (morphemes)
TTR
Rater 1
Rater 2
Outcomes of Children with Hearing Loss
Candy Stealing Narrative
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Summary and Implications:
• The majority of children with mild to severe hearing
loss performed within the average range on
standardized language measures
– But less well than the NH control group
• Syntax and morphology appear to be vulnerable for
some children
– We are continuing to explore contributing factors
(phonology, aided hearing, speech perception)
• Delays were observed on social reasoning tasks
– Which may be related to conversational access
• Clinically we should to go beyond standard
measures to identify areas of need for individual
children
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Academics
Outcomes from 4 to 7 Years
Pre-literacy (4 & 5 Years)
Reading (6 Years)
Spelling and Math (7 Years)
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Questions and Approach
• Does preschool hearing status place
children at risk for poor academic outcome?
• Hearing Status
– As a diagnostic category (HH, NH)
– In terms of degree of unaided hearing (PTA).
– In terms of aided hearing (SII).
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
4 Year Protocol
• Participants
• Measures
Test of Preschool Literacy (TOPEL)
Phonological Awareness
Print Knowledge
– HH = 104
– NH=41
Better Ear SII
Better Ear PTA
29 33 24 25
American Speech-Language Hearing Association, 2011
71>
61-70
51-60
41-50
21-40
12 12
<20
40
30
20
10
0
50
40
30
20
10
0
43
18 22
13 16
Outcomes of Children with Hearing Loss
TOPEL
Knowledge of Print
Phonological Awareness
100
p<0.0001
50
0
88.9
102
HH
NH
120
100
80
60
40
20
0
103.8
106
HH
NH
η2 =.25
η2 =.28
0-20
21-40
41-50 51-60
Better Ear PTA
61-70
American Speech-Language Hearing Association, 2011
>70
.96-1.0
.86-.95
.76-.85
.66-.75
<.65
Better Ear SII
Outcomes of Children with Hearing Loss
5 Year Protocol
• Measures
• Participants
CTOPP
Memory for Digits
Non-word Repetition
Elision
Blending
TOPEL Print Knowledge
Peabody Picture Vocabulary Test
– HH = 95
– NH=26
Better Ear PTA
30
25
20
15
10
5
0
26 26
21
Better Ear SII
24
16
American Speech-Language Hearing Association, 2011
4
40
30
20
10
0
29
20
22
17
7
Outcomes of Children with Hearing Loss
CTOPP Subtests
12
11
10
9
8
7
6
5
4
3
HH
NH
9.07 9.92
Sound
Matching
8.89 9.76
7.33 9.68
Digit Mem. Phono. Mem.
Print Knowledge
HH
104.4
NH
109.9
American Speech-Language Hearing Association, 2011
9.46 10.41
9.82 11.24
Elision
Sound Blend
MANOVA F(5,52)=2.89 p=.022
Outcomes of Children with Hearing Loss
Average CTOPP Score and Hearing
0-20
21-40
41-50
51-60
61-70
Better Ear PTA
F(5,98)=2.87 p=.02
η2=.13
American Speech-Language Hearing Association, 2011
>70
.96-1.0
.86-.95
.76-.85
.66-.75
<.65
Better Ear SII
F(4,80)=4.27 p=.003
η2=.18
Outcomes of Children with Hearing Loss
TOPEL Knowledge of Print
0-20
21-40
41-50
51-60
Better Ear PTA
F(5,111)=2.0 p=.08
η2=.08
American Speech-Language Hearing Association, 2011
61-70
>70
.96-1.0
.86-.95
.76-.85
.66-.75
<.65
Better Ear SII
F(4,89)=6.0 p=.0003
η2=.21
Outcomes of Children with Hearing Loss
Hearing Loss and Pre-literacy
• Phonological processing ability, knowledge
of print and oral language are strong
predictors of later reading.
• Aided hearing is moderately associated with
all of these predictors.
• Hearing is less strongly associated with
knowledge of print and this appears to be a
relative strength.
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
6 Year Protocol
• Participants
–
–
–
–
HH =80
NH=28
84% in Kindergarten
No SES differences
Better Ear PTA
25
20
15
10
5
0
American Speech-Language Hearing Association, 2011
• Measures
Woodcock Reading Mastery Test
Word Attack
Word Identification
Paragraph Comprehension.
Better Ear SII
40
30
20
10
0
Outcomes of Children with Hearing Loss
Woodcock Reading Mastery
125
120
115
110
HH
105
NH
100
95
90
110.9 117.5
115 122.4
Word Attack
Word Ident.
104
118
Paragraph Comp
MANOVA F(3,89)=2.89 p=.02
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss
Mean WRMT & Hearing
0-20
21-40
41-50
51-60
61-70
Better Ear PTA
F=(5, 88)=2.82 p=0.02
η2=.14,
American Speech-Language Hearing Association, 2011
>70
.96-1.0
.86-.95
.76-.85
.66-.75
<.65
Better Ear SII
F=(4, 58)=2.23 p=0.07
η2=.10,
Outcomes of Children with Hearing Loss
Predicting 6 Year-old Reading (WRMT)
• 62 Children (HH=50, NH=12)
• 5 Year Predictors
–
–
–
–
PPVT
CTOPP (Phonological Processing)
Knowledge of Print
Better Ear SII
Hierarchical (Unique Variance) R2=.40 (p=.0001)
Predictor
Standardized Beta
p
PPVT
0.59
0.56
CTOPP
1.16
0.08
Knowledge of Print
1.96
0.06
Better Ear PTA
-1.32
0.19
Step-wise Entry (Best combination)
Predictor
Partial R squared
p
PPVT
0.33
0.0001
Knowledge of Print
0.08
0.03
American Speech-Language Hearing Association, 2011
5 Year Hearing
Predictor
Standardized Beta
p
Better Ear PTA
-1.54
0.13
Better Ear SII
032
0.75
Step-wise Entry
Predictor
Partial R squared
p
Better Ear PTA
0.21
0.001
Outcomes of Children with Hearing Loss
Early Reading & Hearing
• Early predictors of reading are strongly
associated with later reading.
• Most children who are HH fare well in early
reading development despite moderate risk
signaled by weak language and phonological
processing abilities.
• Knowledge of print may serve as a source of
resilience in early reading development.
• Will later reading skills also be spared?
American Speech-Language Hearing Association, 2011
Outcomes of Children with Hearing Loss