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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 3 • • • • STUDY OVERVIEW SERVICE PROVIDER FINDINGS • Questionnaire overview • Service providers • Description of services Outcomes of Children with Mild-Severe Hearing Loss: Year 3 AUDIOLOGY FINDINGS • Follow-up after newborn hearing screen • Hearing aid use time • Hearing aid fittings COMMUNICATION OUTCOMES FINDINGS • Speech & language • Emergent and early literacy skills • Social-cognitive development • INCONSISTENT ACCESS HYPOTHESIS • PROTECTIVE FACTORS ASHA Convention, 2012 Study Overview Background 5 • • Most outcomes research focused on children who are deaf Challenges with research on children who are hard of hearing: • • • • 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 6 • Early language exposure shapes children’s linguistic development (Hart & Risley, 1995) • • • 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 • • 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 7 • • • 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: • • Ages 6 months to 7 years at entry into study English is primary language spoken in the home • No major secondary disabilities • No cochlear implant • • Current participants • 316 children with hearing loss and 120 children with normal hearing, matched by SES and age Permanent mild to severe bilateral hearing loss • • 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 • Onsite testing of children with parents completing questionnaires • • • • 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 • • • 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 • • • • • Annual telephone questionnaire with parents Audiology service provider survey (online) Service provider survey (online) • Birth to three • Preschool • School age Teacher survey • Preschool • School age Medical records • 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? • • • • 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 • Service Provider Surveys • • • • • • 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 20 This Joint Committee identified several key areas: • • • 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 24 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 25 • • 96% reported having certification in the area of employment 60% have completed specialized continuing education in the childhood hearing loss • • Ranging from half day in-service to multiple semester coursework Experience between 0 and 36 years of EI service • • 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 26 • Bachelor’s degree in Deaf Ed. • • • • • Master’s Degree in SLP • • • • • 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 • • • • 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 27 % 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 29 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 • • • • • 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 33 • Does provider specialization: • • • • • • 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 • • “Factors influencing follow-up to newborn hearing screening for infants who are hard of hearing” (Holte et al., 2012) Research questions: • • • • 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 • • • • • • 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 • • • 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? • • “Predictors of hearing aid use time in children with mildsevere hearing loss” (Walker et al., in press) Research questions: • • • • 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 • • • Hearing aid questionnaire average # of hours child used HAs per day consistency of use, rating how often the child wore HAs in 8 contexts • • • 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? • Chronological age, better-ear PTA, maternal education level, and test site had significant effects on daily HA use time. • • • 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? • • • 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. • • • 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 • • 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? • • “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? • Speech intelligibility index (audibility) • • RMS error to target (fidelity of treatment) • • 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: • Manufacturer’s default settings • • Functional gain/Aided soundfield testing • • DO NOT USE: will result in too little amplification for child. ONLY USE: for validating CI & bone conduction devices Speechmapping • • 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 • Timeliness of intervention: • • • 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 • Characteristics of HA fittings • • • 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