Download 1128 Outcomes of Children With Mild-Severe Hearing Loss

OUTCOMES OF CHILDREN WITH MILDSEVERE HEARING LOSS: YEAR 3
SUPPORTED BY NIDCD R01 DC009560
ASHA Convention 2012
ELIZABETH WALKER
SOPHIE E. AMBROSE
THOMAS A. PAGE
Disclosure
2
We have no relevant financial or nonfinancial
relationship(s) within the products or services described,
reviewed, evaluated or compared in this presentation.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Goals of this Presentation
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STUDY OVERVIEW
SERVICE PROVIDER FINDINGS
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Questionnaire overview
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Service providers
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Description of services
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
AUDIOLOGY FINDINGS
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Follow-up after newborn hearing screen
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Hearing aid use time
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Hearing aid fittings
COMMUNICATION OUTCOMES FINDINGS
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Speech & language
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Emergent and early literacy skills
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Social-cognitive development
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INCONSISTENT ACCESS HYPOTHESIS
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PROTECTIVE FACTORS
ASHA Convention, 2012
Study Overview
Background
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Most outcomes research focused on children who are deaf
Challenges with research on children who are hard of hearing:
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Small sample sizes or inclusion of children who are deaf
Did not take amplification history or audibility with hearing aids into
account
Did not include children in the post-UNHS age
2007: National Institutes of Health convened a panel of
professionals and researchers who concluded that there is a
clear need for prospective research to determine what factors
influence success for children who are HH
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Background
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Early language exposure shapes children’s linguistic
development (Hart & Risley, 1995)
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Both quantity and quality contribute to auditory-linguistic
experience (Huttenlocher et al., 1991; Rideout et al., 2003)
Our goal with early amplification is to provide
optimal access to language exposure
New generation of children
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Are they achieving expected outcomes?
Does inconsistent access lead to risk?
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Aims of the OCHL Study
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To describe the characteristics of:
• Children who are hard of hearing and their families
• Intervention services
• Factors associated with service variations
To characterize:
• Developmental, behavioral, and familial outcomes
• Performance compared to same-age, hearing peers with similar
socio-economic backgrounds
Ultimately:
• How do variations in child and family factors and in intervention
characteristics relate to functional outcomes
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Study Domains
Speech
production
Language
skills
Hearing and
speech
perception
Background
characteristics
of
child/family
Academic
abilities
Psychosocial
and
behavioral
Child and
Family
outcomes
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
Interventions
(clinical,
audiological,
educational)
ASHA Convention, 2012
Our Team
9
Mary Pat Moeller, Ph.D. (Co-PI)
J. Bruce Tomblin, Ph.D. (Co-PI)
Patricia Stelmachowicz, Ph.D.
Marlea O’Brien, Program Coordinator
Ryan McCreery, Ph.D.
Rick Arenas, Ph.D. (IT)
Sophie Ambrose, Ph.D.
John Knutson, Ph.D.
Meredith Spratford, Au.D.
Ruth Bentler, Ph.D.
Lauren Unflat Berry, M.S.
Lenore Holte, Ph.D.
Colleen Fitzgerald., M.A.
Elizabeth Walker, Ph.D.
Barbara Peterson (family interviewer)
Connie Ferguson, M.S.
Marcia St. Clair, B.A.
Wendy Fick (data entry)
Melody Harrison, Ph.D.
Jacob Oleson, Ph.D. (biostatistics)
Patricia A. Roush, Au.D.
Jane Pendergast, Ph.D. (biostatistics)
Shana Jacobs, Au.D.
Thomas A. Page, M.S.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Study participants
•
Inclusion criteria:
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Ages 6 months to 7 years at entry
into study
English is primary language spoken
in the home
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No major secondary disabilities
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No cochlear implant
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Current participants
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316 children with hearing loss and
120 children with normal hearing,
matched by SES and age
Permanent mild to severe bilateral
hearing loss
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PTA of 25 to 75 dB HL in better ear
at 500, 1000, 2000, 4000 Hz
Sensorineural, mixed, or permanent
conductive
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
SUBJECTS
BTNRH
UNC
IOWA
TOTAL
HH
121
104
80
305
NH
42
25
53
120
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Distribution of Better Ear PTA
Number
12
40
35
30
25
20
15
10
5
0
27
33
Mean= 48.69
SD=14.11
39
45
51
57
63
69
75
PTA
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Study Design
• Each child followed for at least 3 visits.
• Visits take place at 6, 12 and 18 months, then annually starting
at age 2.
• Retrospective data prior to enrollment obtained by medical
record history.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Sources of data
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Onsite testing of children with parents completing questionnaires
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BTNRH and UNC-Chapel Hill tested at their medical centers
Iowa tested in vans equipped as mobile testing units
Additional travel for out of state testing
LENA project
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Language Environment Analysis
Subset of 41 children who are HH and 17 children with NH, ages 12
months to 3 years
Followed one day per month for one year
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Sources of data
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Annual telephone questionnaire with parents
Audiology service provider survey (online)
Service provider survey (online)
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Birth to three
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Preschool
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School age
Teacher survey
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Preschool
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School age
Medical records
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ENT & pediatrician
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
5 YEAR OLD VISIT (HL)
Test Type
Test Name
Given To
Time
Primary Responsibility
Academic:
CTOPP
TOPEL Print Knowledge
Child
Child
30 minutes
10 minutes
SLP
SLP
Speech Production:
Goldman Fristoe 2
Child
10 minutes
SLP
BIT
PPVT-4
PLAI-2
Theory of Mind Measures
Child
Child
Child
Child
15 minutes
30 minutes
45 minutes
10 minutes
SLP
SLP
SLP
SLP
CELF-4 Word Structure Subtest
Child
15 minutes
SLP
Hx, Audiogram (Conventional) +
Tymps
Electroacoustic Analysis 60/90
Child
30 minutes
Audiologist
Child
5 minutes
Audiologist
Aided Speech Intelligibility Index
(Verefit SII)
PBK
Hearing Aid Checklist
Child
15 minutes
Audiologist
Child
Parent
15 minutes
20 minutes
Audiologist
Audiologist
Adult Perceptions II
Parent
20 minutes
SLP; Audiologist
OCHL Family Interview
Parent
60 minutes
Service
Provider
Service
Provider
Teacher
30 minutes
Language:
Hearing Function:
Psychosocial, Behavioral,
& Family:
OCHL SPS Audiology
OCHL SPS Preschool
SCBE
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
30 minutes
15 minutes
SLP; Audiologist
ASHA Convention, 2012
Where are we now?
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In final year of testing of a 5-year grant cycle
Continuing to test participants and collect data
Continuing to analyze data through our upper ages
Present and Publish findings
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Service Provider Findings
Questionnaire Overview
Service Providers
Description of Services
Next Steps
Questionnaire Overview
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Service Provider Surveys
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Birth to 3, Preschool, & School Age
Once each year the child is enrolled in study
Online response entry
Completion of survey rewarded
Birth-3 responses from 118 professionals
Further informed by Birth to 3 Family Interview
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Service Provision to Children who are Deaf and Hard of
Hearing: Birth to 36 months
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This Joint Committee identified several key areas:
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Providers of services should have expertise in the areas
related to the specific needs of children with all degrees of
hearing loss and and their families
The services provided should be focused on the family; not
simply the child and specified the components that comprise
family-centered services.
To meet the needs of the wide range of hearing losses that
occur and the variety of co-occurring conditions in addition to
hearing loss, services should be interdisciplinary.
ASHA Council on Education of the Deaf: Technical Report 2008
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
21
Professional Identification of Service
Providers
Audiologist
1%
EI Specialist
14%
EC-SP Teacher
6%
TOD-HH
47%
SLP
32%
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Professionals’ Qualifications: Education
22
Degree Make-up
2%
12%
86%
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
Bachelors Only
Masters
Doctorate
ASHA Convention, 2012
Professionals’ Qualifications: Education
23
Primary Degree Disciplines
61%
30%
1% 4%
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
4%
Ed. Of deaf/HoH
SLP
SLP + AUD
Early Child Ed
Audiology
ASHA Convention, 2012
Professionals’ Qualifications: Education
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Certification Beyond Degree Area
n=43
AVT
21%
ECSE
37%
Sp. Ed
2%
ECE
33%
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
Hanen
2%
PITSTOP
5%
ASHA Convention, 2012
Professionals’ Qualifications
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96% reported having certification in the area of
employment
60% have completed specialized continuing
education in the childhood hearing loss
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Ranging from half day in-service to multiple semester
coursework
Experience between 0 and 36 years of EI service
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41% with 0 to 5 yrs
17% with 6 to 10 yrs…
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Cross-section of Specialization
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Bachelor’s degree in Deaf Ed.
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Master’s Degree in SLP
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Local Educational Agency
8 years in EI
Half-day in-service
Caseload: 50 (3 of which have HL)
State Early Interventionist
15 years in EI
Semester course in child HL
Caseload: 27 (100% w/ HL)
Master’s Degree in SLP
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Private center for children with HL
23 years in EI
LSLS Cert. Avt, Hanen Certification
Caseload:13 children on caseload (100% w/ HL)
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Birth to 3 Caseloads
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% of Caseload with HL
100.0
90.0
80.0
n=118
caseload # range= 1-60
caseload mean= 18
% of HL mean= 75.8
% of HL median= 100
PERCENTAGE
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
0
10
20
30
40
50
60
70
80
90
100
110
PROVIDERS
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Birth to 3 Visits per Month
28
20
n=191
mean = 3 visits /month
median = 2 visits/month
18
16
Average 55.9 minutes a visit
VISITS PER MONTH
14
12
10
8
6
4
2
0
0
10
20
30
40
50
60
70
80
90
100
CHILDREN
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
110
120
130
140
150
160
170
180
190
ASHA Convention, 2012
Site of Early Service Provision
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Home
86%
Hospital
Clinic
2%
Txst Office
18%
Center for
Children w
HL
25%
n=181
Daycare
Center
53%
EC Center
2%
Outside Home
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Family Participation by Site
30
Most of the time
Half the time or less
95.5%
71.4%
28.6%
n=181
4.5%
HOME
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
OUTSIDE OF HOME
ASHA Convention, 2012
Interdisciplinary Nature of Services
31
Multi-Disciplinary
Evaluation?
Frequency of Communication
w/ other providers
Frequently
62%
YES
87%
Prefer
Not to
Answer
6%
NO
7%
3-4 Times
per Year
14%
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
1-2 Times
per Year
14%
No Other
Never Providers
9%
1%
ASHA Convention, 2012
Services Summary
32
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Birth to Three service providers are diverse in
discipline, education, and levels of specialization
(“expertise”)
Majority of these providers primarily treat children
with hearing loss
Majority of these children are seen less than weekly
Most services are received in the home
Family participation reduced in services outside of the
home
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Next Steps
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Does provider specialization:
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influence outcomes in speech, language,…
relate to parent satisfaction and “buy-in” to intervention
impact the amount that amplification is utilized
Many more questions
To what degree, if any, does site of service (and
related characteristics) affect outcomes
Continue this line of work into the pre-k, school-age,
and audiology service provider surveys
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Audiology Findings
Follow-up after newborn hearing screen
Hearing aid use time
Quality of hearing aid fittings
Timing of diagnosis and intervention
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“Factors influencing follow-up to newborn hearing
screening for infants who are hard of hearing” (Holte et
al., 2012)
Research questions:
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How do family and child-specific factors affect timely diagnosis
and follow-up?
How consistently are hard-of-hearing children receiving
appropriate care and follow-up within the best-practice 1-3-6
timeline (JCIH, AAP, NIH)?
What reasons are given by families for delays between various
steps in the EHDI process?
Participants: 193 children in the OCHL sample who
referred on NHS
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
What factors affect follow-up?
18
p = .0445
16
p = .0013
14
Age (Months)
12
p = .0123
10
8
High School or less (n=34)
Some College (n = 65)
6
Bachelors (n = 50)
Post Graduate (n=43)
4
2
0
Age of First Eval
Age of Confirmation
Intervention
Follow Up Step
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
Age HA Fitted
ASHA Convention, 2012
Percentage of children meeting 1-3-6
guidelines following failed NHS
100
90
80
Percent of Group
70
60
50
40
30
20
10
0
Screened by 1 month
First diagnostic ABR by 3
mos
HL confirmed by 3 mos
HA fit within 1 month of HL
confirmation
Entry into EI by 6 months
Follow-Up Steps
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Reported reasons for delays
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Multiple rescreenings (up to 10) or retesting
Family assured that failed screen was caused by
something other than permanent hearing loss
Family told by primary care physician to wait until
behavioral testing was possible
Family or physician did not believe child had a hearing
loss due to observable responses to sound
Difficulty obtaining appointment for ABR, medical
clearance for hearing aids or hearing aid fitting
Recurrent otitis media
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Conclusions
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Many families accessed care following failed newborn
screening within recommended 1-3-6 time frames.
In a group of children who are hard-of-hearing, higher
maternal educational levels were significantly associated
with earlier confirmation of hearing loss and fitting of
amplification. Severity of hearing loss was not.
There remains confusion by some families about the
possibility of hearing loss in infants and toddlers who
display awareness of sound. Educational resources and
training should address this specific gap in understanding.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
What predicts how much children are
wearing hearing aids?
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“Predictors of hearing aid use time in children with mildsevere hearing loss” (Walker et al., in press)
Research questions:
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Which factors predict daily HA use time in children who are
hard of hearing?
How consistently do children wear HAs in different settings?
Are parents accurate at estimating average daily hearing aid
use time?
Participants: 272 HH children in the OCHL sample
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Methods
 Participants
Participants
n=272
M
Range
Age at test
(months)
40.5
5-87
Age HL
confirmed
(months)
11.7
.25-70
Age HA fit
(months)
15.0
1.5-72
Better Ear PTA
(dB HL)
49.6
16.2582.5
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Hearing aid questionnaire
average # of hours child
used HAs per day
consistency of use, rating how
often the child wore HAs in 8
contexts
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Outcomes of Children with Mild-Severe Hearing Loss: Year 3
in the car, school, daycare,
meal times, playing alone,
book sharing, playground,
and in public
situations that were
challenging for consistent HA
use
Hearing aid Datalogging
ASHA Convention, 2012
What factors predict daily HA use time in
children who are hard of hearing?
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Chronological age, better-ear PTA, maternal education
level, and test site had significant effects on daily HA
use time.
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Children who wore their hearing aids for more hours tended
to be older, have poorer hearing, and their mothers tended
to have higher maternal education level.
Children at the UNC site wore HAs one hour longer than
children at the Iowa site, on average.
Child’s gender, age at HA fitting, or length of HA
experience did NOT predict daily HA use time.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
How consistently do children wear hearing
aids in different settings?
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Car: 35% of parents of infants (0-2 yr) responded that their child always used HAs in
the car, compared to 78% of parents of preschool (3-4 yr) and school-age (5-7 yr)
children.
Public: Most parents of older children reported that their child always used HAs in
public settings; infants showed less consistency.
Daycare: Infants (58% “always” responses) were less consistent than preschoolers and
school-age children (approx. 80%).
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Are parents accurate at estimating daily hearing
aid use time?
• Parent report = 10.84
hours
• Data logging = 8.3
hours
• Average difference =
2.6 hours
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Conclusions
•
Severity of hearing loss, age, and maternal education level were
significantly related to the amount of time children wore their
HAs.
Younger children and children with milder hearing losses wore HAs less
consistently than older children and those with more severe hearing loss.
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Parents overestimated the amount of time their child wore their
HAs, but the correlation between parents’ estimates and
datalogging was very high.
Clinicians may rely on parental self-report of HA use time as a
general estimate of how much the child wears HAs.
•
Caveat: HA datalogging and consistency ratings are preferred with
parents of younger children when monitoring device use.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Hearing loss and audibility
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For years, we have looked at audiometric thresholds
(pure tone average) as a predictor of later speech,
language, academic and psychosocial outcomes
We hypothesize that access to speech (via hearing
aids) is more likely to predict the child’s success in
life.
•
•
HOW do we quantify “access to speech”?
Speech Intelligibility Index (i.e., “count the dots”)
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Quantifying audibility: Speech Intelligibility Index
Each dot represents ~1% of the
information contributing to
speech clarity.
Number of dots that are audible
predict how well one
understands quiet speech from a
six foot distance.
The dots are unevenly
distributed, with many more of
them filling in the gray zone
between 1000 and 3000 Hz than
in the 250 to 500 Hz area.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Hearing loss and audibility
49
SII = Sum of
weighted
audibility of
all frequency
bands
OCHL Advisory Board Meeting
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
What is the quality of hearing aid
fittings for children in the real world?
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“The characteristics of hearing aid fittings in infants
and young children” (McCreery, Bentler, & Roush, in
revision)
Research questions:
•
How close are hearing aid fittings to targets?
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Speech intelligibility index (audibility)
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RMS error to target (fidelity of treatment)
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0-1, with 1 = completely audible
RMS error < 5 dB = optimal HA fitting
What impacts quality of HA fittings?
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
How close to the target?
Target vs. Measured SII
1.0
Measured SII
Target SII
0.8
SII
0.6
0.4
0.2
0.0
0
50
100
150
200
Subject Number (n = 208)
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
How well are HAs fit in the real world?
Optimal fitting of
hearing aid (< 5dB
RMS error)
Filled symbols =
rms error < 5 dB
Open symbols =
rms error > 5 dB
n = 195
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
McCreery, Bentler, Roush, in revision
ASHA Convention, 2012
What impacts quality of fitting?
•
Verification technique:
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Manufacturer’s default settings
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Functional gain/Aided soundfield testing
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DO NOT USE: will result in too little amplification for child.
ONLY USE: for validating CI & bone conduction devices
Speechmapping
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Real ear-- most accurate estimate of how child is hearing with
hearing aid on the ear.
Simulated real ear-- estimate of how child is hearing
•
•
Measure RECD to accommodate for differences in ear canal shapes
and sizes (PE tube, TM perf), which can affect thresholds.
Use Average RECD when unable to measure.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Summary for audiology section
54
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Timeliness of intervention:
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Higher levels of maternal educational levels were significantly
associated with earlier confirmation of hearing loss and HA
fitting.
32% of HH children met all three JCIH benchmarks – screened
by 1 m, confirmed by 3 m, intervention by 6 m.
Characteristics of daily HA use time:
• Younger children and children with milder hearing losses
wear HAs less consistently than older children and those
with more severe hearing loss.
• Parents tend to overestimate daily HA use time, but the
correlation between parents’ estimates and datalogging
is very high.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Summary for audiology section
55
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Characteristics of HA fittings
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There are a number of children who could be more
optimally fit with HAs
Verification techniques influence optimality of HA fittings
How do these factors relate to speech and language
outcomes?
•
We see variability in the length of HA experience, amount
of HA use, and amount of aided audibility (SII) – these
factors may directly influence outcomes or interact to
influence outcomes.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Communication Outcomes Findings
Relative vulnerability of outcomes
Speech and language
Emergent and early literacy skills
Social-cognitive development
Inconsistent access hypothesis
Protective factors
Relative vulnerability to effects of HL
HH Group
NH Group
55
70
BELOW AVERAGE
100
85
AVERAGE
115
130
145
ABOVE AVERAGE
VOCABULARY SKILLS
GRAMMAR USE
SPEECH PRODUCTION
PRINT KNOWLEDGE
PHONOLOGICAL
AWARENESS
SOCIAL REASONING
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Communication Outcomes Findings
Relative vulnerability of outcomes
Speech and language
Emergent and early literacy skills
Social-cognitive development
Inconsistent access hypothesis
Protective factors
Language: CASL, 3 Years
59
Mean Standard Scores
M = - 0.59
M = - 0.59
M = - 0.73
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
CASL Subtest
NH
(n=42)
HH
(n=116)
Basic Concepts**
104.4
94.3
Pragmatic**
99.0
89.6
Syntax**
94.0
83.7
ASHA Convention, 2012
Language: MBCDI Upper Extension, 3 Years
60
**
**
M = - 0.53
M = - 0.52
**
NH n = 35
HH n = 90
M = - 0.73
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Language: PPVT and CELF, 5 years
61
Mean Standard/Scaled Scores
M = - 0.95
M = - 1.23
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
NH
(n=45)
HH
(n=112)
PPVT**
114.7
101.8
CELF Word
Structure**
12.4
8.8
ASHA Convention, 2012
Language: PPVT and CELF, Longitudinal
62
PPVT, HH n = 33
M = - 1.30
M = - 1.39
CELF Word Structure, HH n = 34
M = - 1.75
M = - 1.53
No significant difference from ages 5 to 7 for either test (ps > .30).
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Speech: GFTA
63
GFTA-2, Cross-sectional results for NH and HH groups at 3, 5, 7 years
ns and Mean Standard Scores
NH
Age
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
HH
n
M
n
M
3 Year**
43
99.3
116
84.7
5 Year**
44 105.3 125
91.6
7 Year**
24 103.9
93.7
70
ASHA Convention, 2012
Speech: GFTA, Longitudinal
64
GFTA
n = 36
n = 33
M = - 0.94
M = - 1.24
M = - 1.43
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
M = - 1.20
No significant
differences between 3
and 5 year scores (p
=.110) or
5 and 7 year scores (p
= .318).
ASHA Convention, 2012
Communication Outcomes Findings
Relative vulnerability of outcomes
Speech and language
Emergent and early literacy skills
Social-cognitive development
Inconsistent access hypothesis
Protective factors
Early Literacy: TOPEL, 4 years
66
Mean Standard Scores
M = 0.16
M = -0.78
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
TOPEL Subtest
NH
(n=49)
HH
(n=116)
Phonological
Awareness**
102.7
90.1
Print
Knowledge
103.6
105.8
ASHA Convention, 2012
Early Literacy: TOPEL and CTOPP, 5 years
67
ns and Mean Standard Scores
NH
n
M = -0.24
M = -0.64
M = -0.83
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
HH
M
n
M
TOPEL
PK
45
108.4 128 105.7
CTOPP
PA**
41
101.5
99
94.1
CTOPP
PM**
41
98.6
99
89.6
ASHA Convention, 2012
Early Literacy: WRMT-R, 6 Years
68
Woodcock Reading Mastery Test - Revised
Mean Standard Scores
M=-0.42
M=-0.56
M=-0.34
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
WRMT-R Subtest
NH
(n=37)
HH
(n=110)
Word Attack*
118.7
111.5
Passage
Comprehension**
117.8
106.6
Word ID
121.8
114.9
ASHA Convention, 2012
Communication Outcomes Findings
Relative vulnerability of outcomes
Speech and language
Emergent and early literacy skills
Social-cognitive development
Inconsistent access hypothesis
Protective factors
Social Cognition (Theory of Mind), 5 years
70
n = 45
n = 123
NH pass
rate = 84%
HH pass rate
= 36%
Between
groups X2:
p < .001
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Relative vulnerability to effects of HL
HH Group
NH Group
55
70
BELOW AVERAGE
100
85
AVERAGE
VOCABULARY SKILLS
115
130
145
ABOVE AVERAGE
Less vulnerable (strength)
GRAMMAR USE
More vulnerable
SPEECH PRODUCTION
More vulnerable
PRINT KNOWLEDGE
Less vulnerable (strength)
PHONOLOGICAL
AWARENESS
More vulnerable
SOCIAL REASONING
More vulnerable
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Inconsistent access hypothesis
Why are children with hearing loss at risk for
communication delays and why are some
domains more vulnerable than others?
Inconsistent access hypothesis
73
Children with hearing loss experience inconsistent access
to linguistic input, due to:
•
Periods without amplification
•
•
•
Limitations of hearing aids
•
•
•
Delays in hearing aid fitting
Inconsistent hearing aid use
Bandwidth
Audibility
Interaction of HL with negative environmental acoustics:
distance, noise, and reverberation
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
74
Inconsistent access hypothesis: Areas of
vulnerability
•
Effect of HL on language development interacts with the
degree to which language learning requires processing
of subtle acoustic cues and the audibility of those cues.
•
Morphemes, especially for verbs, have low phonetic
substance (Hseih, Leonard, & Swanson, 1999)
•
•
•
•
Less frequent in the input
Typically sentence medial (He needs to find…)
Often involve fricatives in English
Complex phonetic contexts (It’s, Greg’s calling…)
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
75
Inconsistent access hypothesis: Areas of
vulnerability
•
•
Accessing multi-talker conversations may also be
especially difficult, leading to delays in social
cognitive development.
Social-cognitive development may also be affected
by weaknesses in syntax/language and other factors.
More research is needed on the mechanisms that
affect development in this domain.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
76
Protective Factors
What protective factors result in resilience?
Protective Factors
•
•
•
•
•
•
Milder degree of hearing loss
Better audibility
Well-fit amplification
Early hearing aid fitting
Amplification worn consistently
Timely and effective early interventions
•
•
•
•
Focused exposure
Increased quantity of linguistic input in the home
More resourced homes
Strong cognitive abilities
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Severity of hearing loss
78
CASL Composite, 3 years
GFTA, 3 years
Level
GFTA
n
CASL
n
NH
43
42
25-35
15
17
36-45
26
27
46-55
33
34
56-65
21
20
66-75
13
12
At 3 years, BEPTA correlated with GFTA (r = -.398**) and CASL Composite (r = -.330**).
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Hearing aids: Audibility
Z-Score (Compared to NH Group)
79
3
Relationship of Audibility with Outcomes (3 years)
2
1
GFTA
r = .441**
0
CASL
r = .250**
-1
-2
-3
-4
0.00
0.20
0.40
0.60
0.80
1.00
Better Ear SII (Audibility)
Aided audibility is a better predictor of outcomes than unaided hearing.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
80
Hearing aids:
Audibility & daily HA use
Amount of daily HA use
•
•
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
At 3 years of age, amount of daily
HA use was not independently
predictive of outcomes. However, daily
HA use interacted with audibility.
Audibility affected outcomes least for
children with the highest amounts of
daily HA use - that is, when children’s
HAs don’t provide them with good
access to the speech spectrum,
consistently wearing their HAs is
especially beneficial.
ASHA Convention, 2012
Hearing aids:
Audibility & length of HA experience
81
Length of HA experience
•
•
•
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
Length of experience with hearing
aids was calculated for the 3-year-old
group by subtracting age at HA fitting
from chronological age.
Experience with HAs was not
independently predictive of
communication outcomes. However,
length of HA experience interacted
with audibility.
Audibility affected outcomes least for
children with the most hearing aid
experience (fit with hearing aids the
earliest).
ASHA Convention, 2012
Early Intervention Services
82
Contribution of number of early intervention visits per
month to CASL Scores at 3-years (regression results)
37%
40%
Covariates (sex, race, maternal
ed**, PTA)
Number visits per month**
23%
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
Unexplained
ASHA Convention, 2012
Linguistic input
83
•
•
Automated analyses were utilized to
examine full-day recordings of the
auditory environments of 28 HH 2
year olds.
Children administered Mullen Scales of
Early Learning (MSEL) at 2 years and
the CASL at 3 years.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Linguistic input
84
Receptive
80
The number of parent-child
conversational turns was significantly
correlated with children’s concurrent
receptive and expressive language
abilities (r = .661**, r = .454**), as
well as their language abilities at 3
years (r = .449**).
Expressive
MSEL T-Score
70
60
50
40
30
20
0
20
40
60
80
100
Conversational Turn Count (per hour)
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Linguistic input
Conversational Turn Count
100
Conversational interactions
were less frequent in homes
with high rates of audible
television, which in turn
predicted weaker language
skills for HH toddlers in those
homes.
r = -0.52**
80
60
40
20
0
0
5
10
15
20
Electronic Media (percent of recording)
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Parent resources
86
Relationship of Maternal Education with Outcomes
Z-Score (Compared to NH Group)
GFTA r = .236*
CASL r = .360**
3
2
Income also
significantly correlated
with GFTA (r = .198*)
and CASL Composite
(r = .306**).
1
0
-1
-2
-3
-4
9
12
15
18
21
Maternal Education (years)
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Cognitive abilities
87
Z-Score (Compared to NH Group)
Relationship of non-verbal IQ at 4 years with language at 5 years
WPPSI Block Design
PPVT, r = .462** CELF Word Structure , r = .410**
2
1
Similar results for
WPPSI Matrix
Reasoning (PPVT:
r = .508**, CELF
Word Structure:
r = .455**)
0
-1
-2
-3
-4
-4
-3
-2
-1
0
1
2
WPPSI Z-Score (Compared to NH Group)
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Summary
88
•
•
Hearing loss places children at risk for delays in
communication development – risk is most often
realized in areas that require access to structural
aspects of language or multi-talker conversations.
Protective factors include early and consistent use of
well-fit hearing aids, appropriate early intervention
services, high rates of linguistic input, and a variety of
other parent and child factors.
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Summary
89
•
•
Although between-group differences existed on most
communication outcome measures, the HH group often
performed within one standard deviation of the NH
group.
The question arises – “What does it mean to be
functioning at the bottom of the average range and
why do we need to focus on protective factors?”
•
•
Our theory: Cascading effects
Need to examine school-age outcomes
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012
Thank you
90
We’d like to thank our OCHL families and service
providers for their continued support and
encouragement.
www.ochl-study.org
Outcomes of Children with Mild-Severe Hearing Loss: Year 3
ASHA Convention, 2012