Download Arlene Stredler-Brown

Minimal Hearing Loss:
Impact & Treatment
Arlene Stredler Brown
Colorado School for the Deaf and the Blind (CSDB)
University of Colorado - Boulder
Marion Downs Hearing Center @ University of Colorado Hospital
Collecting the Evidence;
Asking the Questions
• A portion of school-age children with
unilateral hearing loss experience
academic delays….. Do children with UHL,
in the birth – 3 population, experience
delays? If so, is the percentage the
same?
• Do children, birth – 3, with minimal hearing
loss require intervention?
Part C Eligibility for Children with
Minimal Hearing Loss..
(NCHAM Survey, 2002)
• 46 states (including DC) reporting:
– All 46 states have established risk conditions
that make a child eligible for Part C-funded
services
– 40 states list specific conditions for eligibility
– 30 states note hearing loss as a specific
condition
– 15 states operationally define hearing loss in
their State Plan or other official documents
State of the States
• 11 states define mild hearing as eligible for Part
C services
• 7 states define UHL as eligible for Part C
services (some limit degree of hearing loss)
• Some states require an eligible condition to be
associated with a “high probability of significant
developmental delay” (>90%)
• Some states determine eligibility if/when
“appropriate treatment still leaves significant
impairment”
Eligibility for EHDI Programs
• Each state operationally defines their own
screening procedures, diagnostic criteria,
and early intervention
• Intervention is, to varying degrees,
determined in collaboration with different
initiatives & funding sources
– Part C
– Schools for the Deaf
– Private treatment centers
Collecting the Evidence
Mild Hearing Loss
Mild Hearing Loss: Colorado
Outcome Data
• As a group, children with mild, bilateral
hearing loss have better language skills
than children with more severe degrees of
hearing loss
• As a group, children with mild, bilateral
hearing loss do not have language
quotients comparable to their hearing
peers
Treatment Data
• Colorado’s model supports direct services
to all children with bilateral, mild hearing
loss
• Intensity of services is identified on the
IFSP
The early identification effect on language
(N=85)
Mild Loss
Moderate Loss
Moderate / Severe
Severe Loss
Profound Loss
Mom < HS Education
Mom > HS Education
No Medicaid
Medicaid
Hearing Loss Only
Multiple Disabilities
MCDI Total Language Quotient (Mean)
After 6 Months
By 6 Months
Yoshinaga-Itano, et al (1998)
Collecting the Evidence
Unilateral Hearing Loss
History of the Colorado Project…
• Identification of need subsequent to the
start of UNHS
– BCHD repeatedly asked for guidance for
families of very young children with UHL
• Started in 1997 by the Colorado Home
Intervention Program (CHIP) at the
Colorado School for the Deaf and the
Blind (CSDB) in collaboration with the
University of Colorado-Boulder
History
• Purpose: To identify if the negative impact
of UHL on some school-age children is
apparent during the birth – 5 years
• Purpose: To confirm a need to change
current practices regarding young children
with UHL
– “Don’t worry, your child has one good ear”.
– “Be sure to arrange for preferential seating
when your child starts school”.
Guiding Principles
• Establish an assessment protocol to monitor
development of individual children and the total
group
• A professional with expertise related to hearing
loss is the family’s primary contact person,
answers questions, provides consultation
• The audiologist coordinates with the other
professionals involved in the child’s/family’s
care; physician, clinical audiologist, Part C
service coordinator, direct service providers
Participants in the Project
• Six counties in Denver-metro area
• 30 children in the original database
– Identified by diagnosing audiologist and/or EHDI
database at CDPHE
• Designated service coordinator (a clinical
audiologist) contacts families
– Initial contact by phone
– Offers home visit
– Provides written materials: UHL brochure, CHIP
brochure, “Tips for UHL”, current articles
– Explains pilot project including FAMILY Assessment
The FAMILY Assessment
• Multi-disciplinary assessment consisting of
videotaped interaction and parent-completed
protocols
– Receptive & expressive language: vocabulary, syntax,
speech intelligibility, articulation
– Cognitive/play skills
– Gross/fine motor skills
– Social-emotional skills
– Functional auditory skill development
– Functional vision checklist
– Family Needs Survey
Unilateral to Bilateral Loss
• 30 children initially identified with unilateral
loss
– 2 (7%) progressed to bilateral within first year
of life
– 2 (7%) later diagnosed with bilateral losses
that apparently were present from birth
• One mild (30dB) in poorer ear
• One moderate low frequency loss with
normal high frequency hearing
State of Residence
n
%
Colorado
24
92
New Mexico
1
4
Virginia
1
4
Gender
n
%
Male
14
54
Female
12
46
Ethnicity
Caucasian
Asian American
African American
Hispanic
Hispanic/Caucasian
Other mixed minority
n
18
2
1
2
1
2
%
69
8
4
8
4
8
Additional Disabilities
n
%
No disabilities
22
85
Additional disabilities
4
15
Socio-Economic Status
Range
Years of educ
Mother
12 to 21
Father1
12 to 20
Income2
<$10,000 to
>$100,000
1n
= 24
2n
= 22
Median
16
16
$60,000
Mode of Communication
n
%
Oral
17
65
Occasional sign
7
27
Frequent sign
2
8
Newborn Hearing Screening
n
%
Screened
23
89
Not screened
2
4
Don’t know
1
4
(child adopted)
Age of Identification
n
%
< 6 months
22
92
14 months
1
4
18 months
1
4
N = 24
Age of Onset
Congenital
Acquired
n
%
22
2
88
8
1
4
- 1 at 4 days (meningitis)
- 1 at 3 months (seizures)
Don’t know
N = 25
Etiology
Unknown
Heredity
Waardenburg
Meningitis
Seizures
n
20
3
1
1
1
%
77
12
4
4
4
Malformation of Ear Structures
n
%
Atresia
6
23
Mondini
2
8
None
18
69
Ear with Hearing Loss
n
%
Right
14
54
Left
12
46
Degree of Loss
Mild
Moderate
Moderate-severe
Severe
Severe or profound
N = 25
n
2
6
6
4
7
%
8
24
24
16
28
Language Ability
• Assessments:
– Minnesota Child Development Inventory
– MacArthur Communicative Development
Inventories
– Spontaneous language sample
Minnesota Inventory
• Participant Description:
– 18 children
– No additional disabilities
– Selected oldest age available
– Chronological age:
• Range = 7 to 59 months
• Mean = 25 months
Minnesota Inventory
• Test Description
– Parent report questionnaire
– Expressive and receptive language
subscales
– Language Quotient (LQ) derived
• Language age/Chronological age x 100
• LQ of 100 means language age =
chronological age
Minnesota Inventory
n
%
Expressive
Borderline (70 – 79)
Average (80+)
3
15
17
83
Receptive
Below average (< 70)
Borderline (70 – 79)
Average (80+)
1
3
14
6
17
78
5% of hearing children borderline or below average
MacArthur Inventory:
Expressive
• Participant Description:
– 12 children
– No additional disabilities
– Chronological age:
• Range = 14 to 28 months
• Mean = 21 months
MacArthur Inventory: Receptive
• Participant Description:
– 11 children
– No additional disabilities
– Selected all children who were the
appropriate age for the test
– Chronological age:
• Range = 12 to 16 months
• Mean = 14.5 months
MacArthur Inventories
• Test Description
–Assesses vocabulary abilities
–Parent report questionnaire
–Parent indicates words child can
understand and produce
–Percentile scores determined
relative to test norms
MacArthur Inventories
n
%
Expressive
< 10th percentile
> 10th percentile
2
10
17
83
Receptive
< 10th percentile
> 10th percentile
2
9
18
82
10% of hearing children would be expected to fall below the 10th percentile
Spontaneous Language Sample
• Participant Description:
– 15 children
– No additional disabilities
– Selected oldest age available for
each child
– Chronological age:
• Range = 15 to 62 months
• Mean = 29 months
Spontaneous Language Sample
• Mean Length of Utterance (MLU)
–10 (67%) children within age
expectations
–5 (33%) children below age
expectations
Summary of Language Results
• 15 children examined across measures
and time
– Considered assessments after 12 months of
age
– No additional disabilities
– Number of children with language delays
• Delayed = 4 (27%)
• Borderline = 1 (7%)
Profile of 4 Children with
Delays
•
•
•
•
•
•
•
Caucasian
Identified by 2 months of age
Congenital
Etiology unknown
Parents use oral communication only
Parental education 16 years or more
Annual income > $80,000
Profile of Children with Delays
• No outer or middle ear malformation
• Affected ear: 50% right, 50% left
• Degree of loss
– All “severe or profound” (i.e., no
response on ABR) or profound
Current Case Studies from
Colorado
• 5 children with delays on developmental
assessments
– Chronological ages: 1-5 to 1-11
– Developmental delays in the following areas
• Vocabulary development (n=5)
• Receptive language (n=1)
• MLU (n=1)
• Speech development (n=1)
Let’s remember……
Minimal is not inconsequential
Bess, 2004