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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