Grammatical outcomes of 3- and 6-year-old children who are hard of hearing

Expressive vocabulary word categories of children who are deaf and hard-of-hearing

This study investigated the acquisition of early expressive vocabulary among young children who are deaf and hard-of-hearing (DHH; n = 68) using auditory technology (hearing aids and cochlear implants). Parents completed a standardized vocabulary checklist, which allowed analyses of (i) the size of their child's spoken vocabulary; (ii) composition of the expressive lexicon (e.g., parts of speech such as nouns and verbs; semantic categories such as routines and body parts); and (iii) demographic and audiologic factors (e.g., chronologic age, degree of hearing access) potentially associated with these metrics. Young children who are DHH and use auditory technology acquired fewer spoken words than peers with typical hearing (TH) matched for chronologic age but more spoken words than peers with TH matched for listening experience. Action verbs-not nouns-significantly increased the odds of a child who is DHH achieving a vocabulary quotient within the normative range. These findings support the exploration of early expressive vocabulary size and composition-especially the number of active verbs-to guide clinical management and decision-making for young children who are DHH.

Narrative Intervention for Preschoolers Who Are Deaf and Hard of Hearing Using Listening and Spoken Language: A Pilot Study

PURPOSE

This pilot study aimed to examine the effects of a caregiver-supported, narrative-based intervention program on the story retelling skills of a group of preschoolers who are deaf and hard of hearing (D/HH) using listening and spoken language (LSL).

METHOD

A concurrent multiple baseline design across participants was used to determine the effect of a narrative intervention on the story retelling skills of three preschool-age participants who demonstrated complex language delays. Their primary caregivers also functioned as participants. The 6-week narrative intervention program was implemented using a caregiver coaching model during individual therapy sessions. The dependent variable probes were administered twice per week across phases to assess the preschool participants' story retelling skills, including story grammar, complexity, and completeness. Social validity was also evaluated using a caregiver questionnaire.

RESULTS

A functional relation was demonstrated between the intervention and story retelling across all three preschool participants with notable increases in the inclusion of story grammar elements and episodic completeness. All three participants maintained scores above baseline levels on dependent variable probes across the 6-week maintenance period. Social validity was strong according to the results of a caregiver questionnaire completed at the conclusion of the intervention.

CONCLUSION

These findings offer preliminary support for the use of a caregiver-supported, narrative-based intervention program to improve storytelling and retelling skills in preschoolers who are D/HH using LSL.

Comparing criteria for deviation from hearing aid prescriptive targets in children

OBJECTIVE

To determine if a stricter criterion for paediatric hearing aid fitting for proximity of fit-to-target of <3 dB root-mean-square (RMS) error produces better audibility and outcomes compared to the current <5 dB criterion, and to examine the relationship between aided audibility and RMS error by degree of hearing loss.

DESIGN

We evaluated the influence of unaided hearing level on the relationship between RMS error and aided audibility. We assessed the effect of RMS error category (<3, 3-5, >5 dB) on aided audibility, speech recognition, expressive vocabulary, and morphosyntax.

STUDY SAMPLE

The study included 2314 hearing aid verification measurements from 307 children with hearing aids.

RESULTS

Children who met a <3 dB criterion had higher aided audibility than children who met no criterion (>5 dB error). Results showed no differences in speech recognition or vocabulary by error category, but children with <3 dB error demonstrated better morphosyntax than children with 3-5 and >5 dB RMS error.

CONCLUSIONS

Fittings that are close to prescriptive targets provide a more positive outcome for children with hearing aids. Using probe microphone measures to adjust hearing aids to within 3 dB may benefit language abilities in children.

Early cochlear implantation supports narrative skills of children with prelingual single-sided deafness

Prelingual single-sided deafness (SSD) not only affects children's hearing skills, but can also lead to speech-language delays and academic underachievement. Early cochlear implantation leads to improved spatial hearing, but the impact on language development is less studied. In our longitudinal study, we assessed the language skills of young children with SSD and a cochlear implant (CI). In particular, we investigated their narrative skills in comparison to two control groups: children with SSD without a CI, and children with bilateral normal hearing. We found that children with SSD and a CI performed in line with their normal-hearing peers with regard to narrative and verbal short-term memory skills. Children with SSD without a CI had worse narrative (group difference = - 0.67, p = 0.02) and verbal short-term memory (group difference = - 0.68, p = 0.03) scores than the implanted group. Verbal short-term memory scores and grammar scores each correlated positively with narrative scores across all groups. Early grammar scores (at 2-3 years of age) could partially predict later narrative scores (at 4-6 years of age). These results show that young children with prelingual SSD can benefit from early cochlear implantation to achieve age-appropriate language skills. They support the provision of a CI to children with prelingual SSD.

Werfel K. An Analysis of Mental State Verb and Complex Syntax Use in Children Who Are Deaf and Hard of Hearing

PURPOSE

Children who are deaf and hard of hearing (DHH) have documented deficits with complex syntax and vocabulary knowledge. Mental state verbs (MSVs) are necessary for some kinds of complex syntax use and communicate abstract concepts needed for academic language. The purpose of this study was to examine the frequency, diversity, and syntactic context of MSV use in children who are DHH compared to children with typical hearing (CTH).

METHOD

Seventy-three preschool children (23 with cochlear implants, 22 with hearing aids, and 28 with typical hearing) completed a structured language sample as part of a larger assessment battery. Samples were analyzed and compared across groups for use of MSVs, diversity in MSV use, and syntactical context for MSVs.

RESULTS

Children who are DHH used significantly fewer MSV in complex syntax, a smaller diversity of MSV, and significantly fewer MSV in obligatory contexts compared to CTH. Results for the cochlear implants and hearing aid groups were not significantly different from one another despite differing levels of hearing loss.

CONCLUSION

Children who are DHH demonstrate significant differences in the rate, diversity, and complexity of MSV use compared to peers with typical hearing.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24091860.

Story Generation and Narrative Retells in Children Who Are Hard of Hearing and Hearing Children

PURPOSE

The primary goal for this study was to compare story generation and narrative retell performance in children who are hard of hearing (CHH) and hearing children. A secondary goal was to determine factors that influence narrative performance. Research on this topic is important because narrative language competency is an essential communication function.

METHOD

Participants included 86 CHH and 53 seven-year-old hearing children who had completed a test battery composed of vocabulary, grammar, phonological processing, story generation, and narrative retell tasks. Coders who were blind to hearing status used a scoring rubric to judge the quality of narrative macrostructure in story generation and narrative retells. Data were analyzed using analysis of variance to determine group differences and correlational models to examine individual differences.

RESULTS

At 7 years of age, CHH demonstrated significant deficits in narrative macrostructure compared to hearing children, with larger delays in narrative retell than story generation. Vocabulary, grammar, and phonological memory acted as mediators in the relationship between hearing status and story generation; grammar acted as a mediator between hearing status and narrative retell. Auditory access variables accounted for a significant proportion of shared variance in story generation skills for CHH.

CONCLUSIONS

School-age CHH are at risk for delays in narrative production, particularly with retelling stories. The results of this study highlight a narrative coding approach and task procedures that are sensitive to differences in language levels and may be clinically useful for professionals working with early school-age children.

Hearing Thresholds, Speech Recognition, and Audibility as Indicators for Modifying Intervention in Children With Hearing Aids

OBJECTIVES

The purpose of this study was to determine if traditional audiologic measures (e.g., pure-tone average, speech recognition) and audibility-based measures predict risk for spoken language delay in children who are hard of hearing (CHH) who use hearing aids (HAs). Audibility-based measures included the Speech Intelligibility Index (SII), HA use, and auditory dosage, a measure of auditory access that weighs each child's unaided and aided audibility by the average hours of HA use per day. The authors also sought to estimate values of these measures at which CHH would be at greater risk for delayed outcomes compared with a group of children with typical hearing (CTH) matched for age and socioeconomic status, potentially signaling a need to make changes to a child's hearing technology or intervention plan.

DESIGN

The authors compared spoken language outcomes of 182 CHH and 78 CTH and evaluated relationships between language and audiologic measures (e.g., aided SII) in CHH using generalized additive models. They used these models to identify values associated with falling below CTH (by > 1.5 SDs from the mean) on language assessments, putting CHH at risk for language delay.

RESULTS

Risk for language delay was associated with aided speech recognition in noise performance (<59% phonemes correct, 95% confidence interval [55%, 62%]), aided Speech Intelligibility Index (SII < 0.61, 95% confidence internal [.53,.68]), and auditory dosage (dosage < 6.0, 95% confidence internal [5.3, 6.7]) in CHH. The level of speech recognition in quiet, unaided pure-tone average, and unaided SII that placed children at risk for language delay could not be determined due to imprecise estimates with broad confidence intervals.

CONCLUSIONS

Results support using aided SII, aided speech recognition in noise measures, and auditory dosage as tools to facilitate clinical decision-making, such as deciding whether changes to a child's hearing technology are warranted. Values identified in this article can complement other metrics (e.g., unaided hearing thresholds, aided speech recognition testing, language assessment) when considering changes to intervention, such as adding language supports, making HA adjustments, or referring for cochlear implant candidacy evaluation.

Language Intervention Instead of Speech Intervention for Children With Cochlear Implants

Cochlear implants are a standard rehabilitation option for children with severe hearing loss or deafness, allowing access to speech sounds necessary for the development of spoken language. However, the speech-language outcomes of pediatric cochlear implant users vary widely and are not directly or exclusively linked to technology but to combinations of individual audiological, personal, technical, and habilitational factors. These combinations may not favor spoken language development, which may further be linked to the issue of prior insistence on spoken language learning and associated with a high risk of language deprivation. Here, we discuss the outcomes of cochlear implantation from a habilitative perspective and lay down the efforts and resources necessary for the development of communication competence after cochlear implantation rather than the achievement of specific hearing, language, or speech skills that have limited socioemotional and educational contributions and do not guarantee an independent or productive life.

Home Literacy Experiences and Shared Reading Practices: Preschoolers With Hearing Loss

Home literacy experiences and observed parent and child behaviors during shared book reading were investigated in preschool-age children with hearing loss and with typical hearing to examine the relationships between those factors and children's language skills. The methods involved parent-reported home literacy experiences and videotaped parent-child dyads during shared book reading. Children's language skills were tested using the Preschool Language Scale-4. The results indicated significant differences between groups for home literacy experiences and observed parent and child behaviors. Parents of children with hearing loss were found to read more frequently to their children than parents of children with typical hearing, yet scored lower for literacy strategies and teaching techniques compared to parents of children with typical hearing. Children with hearing loss scored lower in interactive reading behaviors compared to children with typical hearing. For children with hearing loss, frequency of book reading and child interactive reading behaviors were strong predictive factors for children's language skills. These results suggest that families of children with hearing loss would benefit from professional support as they read storybooks to their children. Similarly, children with hearing loss should be encouraged to be more interactive during shared book reading.

Cochlear Implants or Hearing Aids: Speech Perception, Language, and Executive Function Outcomes

OBJECTIVES

We aimed to determine whether children with severe hearing loss (HL) who use hearing aids (HAs) may experience added value in the perception of speech, language development, and executive function (EF) compared to children who are hard of hearing (HH) or children who are deaf and who use cochlear implants (CIs) and would benefit from CIs over HAs. The results contribute to the ongoing debate concerning CI criteria. We addressed the following research question to achieve this aim: Do children who are HH or deaf with CIs perform better than children with severe HL with HAs with respect to auditory speech perception, and receptive vocabulary and/or EF?

DESIGN

We compared two groups of children with severe HL, profound HL or deafness, with CIs or HAs, matched for gender, test age (range, 8 to 15 years), socioeconomic status, and nonverbal intelligence quotient. Forty-three children had CIs (pure-tone average at 2000 and 4000 Hz >85 dB HL), and 27 children had HAs (mean pure-tone average: 69 dB HL). We measured speech perception at the conversational level (65 dB SPL) and the soft speech perception level (45 dB SPL). We established receptive vocabulary using the Peabody Picture Vocabulary Test-III-NL. We tested EF using the Delis Kaplan Executive Function System battery and the Dutch Rey Auditory Verbal Learning Test. We employed the Mann-Whitney U test to compare data between the CI and HA groups. We used Chi-square goodness of fit tests to contrast the CI and HA group distributions with the norm data of children who are typically developing (TD). We harnessed Kendall's Tau-b to investigate relationships between the study variables.

RESULTS

Both groups of children, with CIs and Has, obtained ceiling scores for perception of speech on a conversational level. However, the HA group exhibited significantly lower perception on a soft speech level scores (68 %) than the CI group (87%). No difference was present between the receptive vocabulary distributions of the CI and HA groups. The median receptive vocabulary standard scores for both groups were well within the normal range (CI group: 93; HA group: 96). In addition, we did not find any difference in EF between the CI and HA groups. For planning and verbal memory, the distributions of observed scores for children with CIs were different from the expected distributions of children who are TD. In both groups, a large proportion of children obtained below-average scores for planning (CI: 44%; HA: 33%) and for long-term verbal memory (CI: 44%; HA: 35%). In the HA group, perception at a soft speech level was associated with receptive vocabulary and planning. In the CI group, we did not find any associations.

CONCLUSIONS

Both groups of children with severe and profound HL with HAs exhibit less favorable auditory perception on the soft speech level, but not at a conversational level, compared to children who are HH or deaf with CIs. Both groups, children with CIs and HAs, only exhibit more problems in planning and verbal memory than the norm groups of children who are TD. The results indicate that to obtain age-appropriate levels of receptive vocabulary and EF, the perception at the soft speech level is a necessary but not sufficient prerequisite.

The Importance of High-Frequency Bandwidth on Speech and Language Development in Children: A Review of Patricia Stelmachowicz's Contributions to Pediatric Audiology

We review the literature related to Patricia Stelmachowicz's research in pediatric audiology, specifically focusing on the influence of audibility in language development and acquisition of linguistic rules. Pat Stelmachowicz spent her career increasing our awareness and understanding of children with mild to severe hearing loss who use hearing aids. Using a variety of novel experiments and stimuli, Pat and her colleagues produced a robust body of evidence to support the hypothesis that development moderates the role of frequency bandwidth on speech perception, particularly for fricative sounds. The prolific research that came out of Pat's lab had several important implications for clinical practice. First, her work highlighted that children require access to more high-frequency speech information than adults in the detection and identification of fricatives such as /s/ and /z/. These high-frequency speech sounds are important for morphological and phonological development. Consequently, the limited bandwidth of conventional hearing aids may delay the formation of linguistic rules in these two domains for children with hearing loss. Second, it emphasized the importance of not merely applying adult findings to the clinical decision-making process in pediatric amplification. Clinicians should use evidence-based practices to verify and provide maximum audibility for children who use hearing aids to acquire spoken language.

Auditory Experience, Speech Sound Production Growth, and Early Literacy in Children Who Are Hard of Hearing

PURPOSE

Children who are hard of hearing (CHH) are at risk for literacy difficulties. Speech sound production is related to literacy skills in typically hearing children. Speech sound production abilities can also be markedly weak in CHH due to inconsistent access to the speech signal. We longitudinally examined relations between auditory experience, speech sound production abilities, and literacy (i.e., nonword reading and spelling in second grade) in CHH.

METHOD

Participants included 166 CHH. All participants used hearing aids (HAs). Auditory experience is a weighted measure of the number of hours of daily HA use and the amount of audibility with and without their HAs. Children's speech sound production was tested 2-3 times between the ages of 3 and 9 years. At age 5 years and again in second grade, children were tested on a battery of language and literacy measures.

RESULTS

Auditory experience was significantly correlated with speech sound production abilities, but age at HA fitting was not. Speech sound production abilities at age 5 years did not predict nonword reading in second grade but did predict spelling skills in second grade.

CONCLUSIONS

Our results support the importance of auditory experience and speech sound production for later literacy abilities. Specifically, we found that speech sound production abilities and print knowledge at age 5 years are related to second grade spelling outcomes. Interestingly, we found that morphological knowledge at age 5 years was more predictive of decoding in second grade than was speech sound production. Although there are multiple factors that contribute to literacy success, our results underscore the unique contributions of speech sound production abilities in CHH.

Correction of the Estimated Hearing Level of NB Chirp ABR in Normal Hearing Population

INTRODUCTION

The narrowband chirp (NB Chirp), a frequency-specific sound stimulus signal obtained by limiting the frequency bandwidth based on chirp, is applied to the frequency specified auditory brainstem response (fsABR) increasingly. Although some studies demonstrated that NB Chirp-evoked auditory brainstem response (NB Chirp ABR) causes a better neural response than tone burst-evoked auditory brainstem response and is preferred for fsABR, there is little known about how to better estimate an individual's hearing level through the threshold of NB Chirp ABR. The present study intended to compare the accuracy and deviation of NB Chirp ABR corrected by different approaches in estimating the hearing level of people with normal hearing.

METHODS

A total of 66 volunteers with normal hearing were randomly divided into a model group (n = 26), test group 1 (n = 20), and test group 2 (n = 20). The model group was used to calculate the threshold difference between NB Chirp ABR and pure-tone audiometry at 500 Hz, 1,000 Hz, 2,000 Hz, and 4,000 Hz, as well as the regression equation, providing a reference for the correction of estimated hearing level of NB Chirp ABR. Test group 1 was used to observe the accuracy and deviation of the "noncorrection (N)," "threshold difference (A1)," and "regression equation (A2)" methods in correcting the estimated hearing level of NB Chirp ABR. Test group 2 was used to replicate the analysis of test group 1 to verify the repeatability of the experimental results. All data were analyzed using SPSS 24.0.

RESULTS

Test group 1 and test group 2 had similar results. First, the accuracy of the estimated hearing level of N was significantly higher than that of A1 or A2. Second, compared with "0," the deviation of the estimated hearing level of N was bigger than that of A1 or A2 at 500 Hz and 1,000 Hz, while similar at 2,000 Hz and 4,000 Hz. Finally, there was no significant difference in the deviation of the estimated hearing level between A1 and A2 at 500 Hz and 1,000 Hz.

CONCLUSION

Among people with normal hearing, it was necessary to correct NB Chirp ABR at 500 Hz and 1,000 Hz for lower deviation of the estimated hearing level. Both correction approaches based on threshold difference and regression equation can be used.

Oral Language Acquisition in Preschool Children Who are Deaf and Hard-of-Hearing

The purpose of this study was to compare developmental trajectories of oral language acquisition of children who are deaf and hard of hearing (DHH) and children with typical hearing across the preschool years. Thirty children who are DHH who use amplification and spoken language and 31 children with typical hearing completed an early language and literacy assessment battery every six months from age 4 to age 6. The developmental trajectories of each group's language skills were examined via growth curve analysis. Oral language skills were lower for children who are DHH than for children with typical hearing at study entry. For vocabulary, children who are DHH demonstrated growth over the two years but did not close the gap in performance over time. For morphosyntax, specifically verb tense marking, children who are DHH demonstrated growth over preschool, becoming more adult-like in their productions.

Naturalistic Use of Aspect Morphology in Deaf and Hard-of-Hearing Children

Grammatical morphology often links small acoustic forms to abstract semantic domains. Deaf and hard-of-hearing (DHH) children have reduced access to the acoustic signal and frequently have delayed acquisition of grammatical morphology (e.g., Tomblin, Harrison, Ambrose, Walker, Oleson & Moeller, 2015). This study investigated the naturalistic use of aspectual morphology in DHH children to determine if they organize this semantic domain as normal hearing (NH) children have been found to do. Thirty DHH children (M = 6;8) and 29 NH children (M = 5;11) acquiring English participated in a free-play session and their tokens of perfective (simple past) and imperfective (-ing) morphology were coded for the lexical aspect of the predicate they marked. Both groups showed established prototype effects, favoring perfective + telic and imperfective + atelic pairings over perfective + atelic and perfective + atelic ones. Thus, despite reduced access to the acoustic signal, this DHH group was unimpaired for aspectual organization.

Spoken Language Skills in Children With Bilateral Hearing Aids or Bilateral Cochlear Implants at the Age of Three Years

Early hearing aid (HA) fitting and cochlear implants (CIs) aim to reduce the effects of hearing loss (HL) on spoken language development. The goals of this study were (1) to examine spoken language skills of children with bilateral HAs and children with bilateral CIs; (2) to compare their language skills to the age-norms of peers with normal hearing (NH); and (3) to investigate factors associated with spoken language outcomes.

Deaf Children of Hearing Parents Have Age-Level Vocabulary Growth When Exposed to American Sign Language by 6 Months of Age

OBJECTIVE

To examine whether children who are deaf or hard of hearing who have hearing parents can develop age-level vocabulary skills when they have early exposure to a sign language.

STUDY DESIGN

This cross-sectional study of vocabulary size included 78 children who are deaf or hard of hearing between 8 and 68 months of age who were learning American Sign Language (ASL) and had hearing parents. Children who were exposed to ASL before 6 months of age or between 6 and 36 months of age were compared with a reference sample of 104 deaf and hard of hearing children who have parents who are deaf and sign.

RESULTS

Deaf and hard of hearing children with hearing parents who were exposed to ASL in the first 6 months of life had age-expected receptive and expressive vocabulary growth. Children who had a short delay in ASL exposure had relatively smaller expressive but not receptive vocabulary sizes, and made rapid gains.

CONCLUSIONS

Although hearing parents generally learn ASL alongside their children who are deaf, their children can develop age-expected vocabulary skills when exposed to ASL during infancy. Children who are deaf with hearing parents can predictably and consistently develop age-level vocabularies at rates similar to native signers; early vocabulary skills are robust predictors of development across domains.

The Production of Complex Syntax in Spontaneous Language by 4-Year-Old Children With Hearing Loss

Purpose Proficiency with complex syntax is important for language and reading comprehension, and production of complex syntax begins to emerge shortly after a young child begins using two-word combinations. Complex syntax production in preschool children with hearing loss who use spoken language has been explored minimally. The purpose of this study was to compare complex syntax production of 4-year-old children with hearing loss to age-matched and language-matched peers with normal hearing. Method Seventy-two children completed a language assessment battery, including a structured language sample. Complex syntax density and number and accuracy of productions of particular types of complex syntax were compared across three groups: 4-year-old children with hearing loss, an age-matched group of children with normal hearing, and an mean length of utterance (MLU)-matched group of children with normal hearing. Results Children with hearing loss had lower complex syntax density and fewer correct productions of coordinated clauses, subordinate clauses, and simple infinitives than their age-matched, but not language-matched, peers. Furthermore, children with hearing loss had lower accuracy than the age-matched group on simple infinitives and lower accuracy than both the age- and MLU-matched groups on full propositional complements and subject relative clauses. Conclusion Children with hearing loss exhibit delays in complex syntax acquisition as compared to their same-age peers and disruptions in development on some complex structures as compared to MLU-matched, younger children. Supplemental Material https://doi.org/10.23641/asha.14080193.

Developmental Outcomes in Early-Identified Children Who Are Hard of Hearing at 2 to 3 Years of Age

OBJECTIVES

This study examined the psychosocial, adaptive behavior, and language outcomes of young children who are hard of hearing (HH) without additional disabilities or neurocognitive impairments. Relations between early developmental outcomes and child and parent demographic variables, and parenting stress and self-efficacy were also explored.

DESIGN

Participants were 39 children with early identified, permanent mild to severe hearing loss, between the ages of 2 and 3 years, and a comparison group of 47 children with normal hearing (NH). Developmental outcomes were measured using clinician-administered standardized tests and parent-completed behavior rating instruments specific to language, psychosocial functioning, and adaptive behavior. Mothers completed self-report measures that assess parenting stress and maternal self-efficacy.

RESULTS

The children who are HH were similar to the children with NH in terms of their psychosocial functioning and adaptive behavior, with the exception of their socialization skills. As a group, the children who are HH performed significantly worse than their peers with NH on all measures of language ability. Among the children who are HH, maternal self-efficacy showed a strong positive correlation with adaptive behavior outcomes; however, it failed to contribute unique variance above that explained by language ability and gender. Maternal self-efficacy was also significantly correlated with better psychosocial outcomes, but only parenting stress proved to be a significant predictor of child behavioral problems once other variables considered were in the model.

CONCLUSIONS

Early-identified young children who are HH can demonstrate age-appropriate development in multiple domains, including language, psychosocial, and adaptive behavior. However, mild to severe hearing loss places young children with no additional disabilities or neurocognitive impairments at risk for language delays. Although the children who are HH demonstrated no more emotional or behavioral problems than their same-age peers with NH, results suggest that language delays increase their vulnerability for delays in various aspects of social competence.

A Technology-Assisted Language Intervention for Children Who Are Deaf or Hard of Hearing: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

Children who are deaf or hard of hearing (DHH) often have persistent language delays despite early identification and interventions. The technology-assisted language intervention (TALI), which incorporates augmentative and alternative communication technology into a speech-language therapy model, was designed to support language learning. The study objective was to evaluate the impact of the TALI on spoken language outcomes in DHH children.

METHODS

Children aged 3 to 12 years with mild to profound bilateral hearing loss were enrolled in a single-site randomized controlled trial. Children were randomly assigned to receive the TALI or treatment as usual (TAU) (with no change in current care) and were followed for 24 weeks. Primary outcomes included spoken language measures elicited from language samples. Secondary outcomes included standardized assessments. Intention-to-treat analyses were used.

RESULTS

Analyses focused on 41 children randomly assigned to TALI (n = 21) or TAU (n = 20). Among all participants, mean age was 6.3 years (SD 2.5). Over 24 weeks, children in the TALI group, compared with those in the TAU group, had significantly greater increases in the length of phrases they used to express themselves (β = .91 vs .15, respectively; P< .0001). Similar findings were seen with conversational turn-taking and number of different words spoken.

CONCLUSIONS

Providing visual supports for language concepts that are typically challenging for DHH children to acquire allowed children to process and comprehend spoken language more fully. Such strategies can mitigate persistent language delays with the goal of improving lifelong outcomes and independence across settings.

A Multilinguistic Spelling Analysis of Children who are Hard of Hearing

Spelling in writing samples was compared between children who are hard of hearing (HH) (n = 142) and their peers with typical hearing (TH) (n = 72) in second and fourth grade. The same analyses were then conducted comparing groups of children who are HH with different levels of aided audibility. Compared to children with TH, children who are HH produced fewer misspelled words (p = .041, d = .42) at second grade but performed similarly in fourth grade (p = .943, d = .02). Compared to peers with TH, children who are HH demonstrated similar distributions of errors in roots but some differences in the distribution of errors for affixes. Different levels of aided audibility among children who are HH were not associated with significant differences in spelling accuracy at both grades. However, second-grade children with poorer aided audibility produced significantly more phonological omissions (p = .005, r = .32) and orthographic consonant errors for monomorphemic words (p = .001, r = .37), as well as more orthographic consonant errors for and affixes (p = .015, r = .28).

Knowledge and Practice of Hearing Screening and Hearing Loss Management among Ear, Nose, and Throat Physicians in Jordan

Introduction  One of the main factors that affect the early diagnosis and intervention of hearing loss is inadequate knowledge by the health care workers. Ear, nose, and throat (ENT) specialists are the main source of information about hearing loss and its management in most developing countries, such as Jordan. Objective  The purpose of the present study is to explore the level of knowledge and the practice of hearing screening and hearing loss management for children among ENT physicians in Jordan as an example of health care providers in developing countries of the Middle East. Methods  This was a cross-sectional study, adapting a questionnaire of knowledge and the practice of hearing screening and hearing loss management for children. The questionnaire consisted of 2 sections with 20 questions. A total of 40 ENT physicians completed the questionnaire. Results  The majority of the respondents acknowledged the importance of hearing screening for children; however, there was limited knowledge regarding hearing loss management and testing. Only 10 of the ENT physicians believed that a referral to an audiologist is warranted, and the majority of the respondents were not aware that a child with a confirmed permanent hearing loss should be referred to a speech pathologist or to a rehabilitation center. Managing unilateral and mild sensorineural hearing loss (SNHL) was another area about which ENT physicians have limited knowledge. Conclusion  There is a strong need for professional intervention programs, providing the latest updates and standardizations in the field of audiology and pediatric rehabilitation for ENT physicians.

Adverse Childhood Communication Experiences Associated With an Increased Risk of Chronic Diseases in Adults Who Are Deaf

INTRODUCTION

This study explores adverse childhood communication experiences and its RRs for acquiring specific chronic diseases and mental health disorders in adults who are deaf and hard of hearing.

METHODS

A cross-sectional design with snowball sampling was used to recruit adults who were deaf and hard of hearing and were born or became deaf in both ears before age 13 years. Patient-reported outcomes surveys in American Sign Language and English were disseminated to collect data about early life communication experiences with caregivers. Modified Poisson regression with robust SEs was used to calculate RR estimates and 95% CIs for all medical conditions with early life communication experiences as main predictors.

RESULTS

Data collection occurred from May 2016 to July 2016, October 2016 to April 2018, and October 2018 to May 2019. The U.S. sample consisted of 1,524 adults who were born or became deaf early. After adjusting for parental hearing status and known correlates of medical conditions, poorer direct child-caregiver communication was significantly associated with an increased risk of being diagnosed with diabetes (RRR=1.12, 95% CI=1.01, 1.24), hypertension (RRR=1.10, 95% CI=1.03, 1.17), and heart disease (RRR=1.61, 95% CI=1.39, 1.87). Poor indirect family communication/inclusion increased risks for lung diseases (RRR=1.19, 95% CI=1.07, 1.33) and depression/anxiety disorders (RRR=1.34, 95% CI=1.24, 1.44). The absolute risk increase and number needed to harm are also reported.

CONCLUSIONS

Outcomes data reported by patients who were deaf and hard of hearing demonstrated that poorer direct child-caregiver communication and ongoing exclusion from incidental family communication were associated with increased risks for multiple chronic health outcomes. Practices should consider developing and utilizing an adverse childhood communication screening measure to prevent or remediate language deprivation and communication neglect in pediatric patients who were deaf and hard of hearing.

The Limits of "Communication Mode" as a Construct

Questions about communication mode (a.k.a. "communication options" or "communication opportunities") remain among the most controversial issues in the many fields that are concerned with the development and well-being of children (and adults) who are d/Deaf or hard of hearing. In this manuscript, we argue that a large part of the reason that this debate persists is due to limitations of the construct itself. We focus on what we term "the crucial question": namely, what kind of experience with linguistic input during infancy and toddlerhood is most likely to result in mastery of at least one language (spoken or signed) by school entry. We argue that the construct of communication mode-as currently construed-actively prevents the discovery of compelling answers to that question. To substantiate our argument, we present a review of a relevant subset of the recent empirical literature and document the prevalence of our concerns. We conclude by articulating the desiderata of an alternative construct that, if appropriately measured, would have the potential to yield answers to what we identify as "the crucial question."

The Input Matters: Assessing Cumulative Language Access in Deaf and Hard of Hearing Individuals and Populations

Deaf and hard-of-hearing (DHH) children present several challenges to traditional methods of language assessment, and yet language assessment for this population is absolutely essential for optimizing their developmental potential. Whereas assessment often focuses on language outcomes, this Conceptual Analysis argues that assessing cumulative language input is critically important both in clinical work with DHH individuals and in research/public health contexts concerned with DHH populations. At the individual level, paying attention to the input (and the person's access to it) is vital for discriminating disorder from delay, and for setting goals and strategies for reaching them. At the population level, understanding relationships between cumulative language input and resulting language outcomes is essential to the broader public health efforts aimed at identifying strategies to improve outcomes in DHH populations and to theoretical efforts to understand the role that language plays in child development. Unfortunately, several factors jointly result in DHH children's input being under-described at both individual and population levels: for example, overly simplistic ways of classifying input, and the lack of tools for assessing input more thoroughly. To address these limitations, this Conceptual Analysis proposes a new way of characterizing a DHH child's cumulative experience with input, and outlines the features that a tool would need to have in order to measure this alternative construct.

Forum on Morphosyntax Assessment and Intervention for Children

Purpose

This forum consists of articles that address the need for and approaches to assessment and treatment of morphology and syntax in children. Drawing on papers submitted by diverse laboratories working with multiple populations, this forum includes several articles describing different approaches to treatment, guidelines for goal setting, and assessment methods. Populations described include monolingual and bilingual children who speak English, Dutch, and Spanish, who use oral language and/or augmentative and alternative communication to communicate.

Conclusion

The current tools available to support traditional grammar therapy are changing and increasing. An emphasis on manualized treatments, treatments that include drill and explicit instruction, and assessment and treatment tools for a variety of populations across a wide age span are included here. Further work is needed to fully develop these promising tools and approaches for the most effective use.

The Acquisition of Productive Plural Morphology by Children With Hearing Loss

Purpose Normal-hearing (NH) children acquire plural morphemes at different rates, with the segmental allomorphs /-s, -z/ (e.g., cat-s) being acquired before the syllabic allomorph /-əz/ (e.g., bus-es). Children with hearing loss (HL) have been reported to show delays in the production of plural morphology, raising the possibility that this might be due to challenges acquiring different types of lexical/morphological representations. This study therefore examined the comprehension of plural morphology by 3- to 7-year-olds with HL and compared this with performance by their NH peers. We also investigated comprehension as a function of wearing hearing aids (HAs) versus cochlear implants (CIs). Method Participants included 129 NH children aged 3-5 years and 25 children with HL aged 3-7 years (13 with HAs, 12 with CIs). All participated in a novel word two-alternative forced-choice task presented on an iPad. The task tested comprehension of the segmental (e.g., teps, mubz) and syllabic (e.g., kosses) plural, as well as their singular counterparts (e.g., tep, mub, koss). Results While the children with NH were above chance for all conditions, those with HL performed at chance. As a group, the performance of the children with HL did not improve with age. However, results suggest possible differences between children with HAs and those with CIs, where those with HAs appeared to be in the process of developing representations of consonant-vowel-consonant singulars. Conclusions Results suggest that preschoolers with HL do not yet have a robust representation of plural morphology for words they have not heard before. However, those with HAs are beginning to access the singular/plural system as they get older.

Language and Reading Outcomes in Fourth-Grade Children With Mild Hearing Loss Compared to Age-Matched Hearing Peers

Purpose There is ambiguity in the clinical and research communities regarding whether children with mild bilateral hearing loss (MBHL) are at risk for delays. The goal of the current article is to expand the evidence base surrounding outcomes for the current generation of children with MBHL. Method Using independent-samples t tests, we compared children with MBHL to same-age peers with normal hearing (NH) on measures of vocabulary, morphological awareness, listening comprehension, and reading. We completed regression analyses to explore the foundational linguistic skills that influenced reading abilities in both groups. For the children with MBHL, we examined whether hearing aid (HA) dosage was associated with individual differences in language scores. Results Group comparisons indicated that children with NH significantly outperformed children with MBHL on tests of morphological awareness and listening comprehension. There were no differences in vocabulary size or reading achievement; however, children with MBHL displayed significant differences in the factors that accounted for variability in reading scores compared to children with NH. HA dosage was significantly associated with variation in listening comprehension scores, but not vocabulary, reading, or morphological awareness. Conclusions The current results provide evidence that children with MBHL are at risk for persistent language deficits by 4th grade, particularly in aspects of language that involve form. Reading skills in children with MBHL appear to be commensurate with same-age hearing peers. Consistent use of well-fit HAs supports listening comprehension, although the amount of benefit from HAs may be reduced for children with higher unaided hearing levels.

Talk with me! Parental linguistic input to toddlers with moderate hearing loss

This study examined the quantity and quality of parental linguistic input to toddlers with moderate hearing loss (MHL) compared with toddlers with normal hearing (NH). The linguistic input to eighteen toddlers with MHL and twenty-four toddlers with NH was examined during a 10-minute free-play activity in their home environment. Results showed that toddlers with MHL were exposed to an equivalent amount of parental linguistic input compared to toddlers with NH. However, parents of toddlers with MHL used less high-level facilitative language techniques, used less mental state language, and used shorter utterances than parents of toddlers with NH. Quantity and quality measures of parental linguistic input were positively related to the expressive language abilities of toddlers with MHL.

Oral Language Performance of Deaf and Hard-of-Hearing Students in Mainstream Schools

In Hong Kong, students are expected to speak fluent Cantonese, Putonghua, and English. However, the curriculum does not include Cantonese studies, as children are expected to have already acquired Cantonese by the age of school entry. This study examined the language outcomes of Cantonese-speaking deaf or hard-of-hearing children who attend primary schools within the Hong Kong educational system and considered whether the system currently meets the needs of these children. The Hong Kong Cantonese Oral Language Assessment Scale, which comprises six subtests, was used to assess 98 children with mild to profound hearing loss. A regression analysis was used to examine the influences of various variables on oral language performance in these children. Notably, 41% of the participants had achieved age-appropriate oral language skills, while 18% and 41% exhibited mild-to-moderate or severe oral language impairment, respectively. The degree of hearing loss and the use of speech therapy were identified as significant negative predictors of oral language performance. The issues of a relatively late diagnosis and device fitting, as well as the very poor oral language outcomes, strongly emphasize the need for policy makers to reconsider the existing educational approaches and support for deaf or hard-of-hearing children.

Linear Mixed-Model Analysis to Examine Longitudinal Trajectories in Vocabulary Depth and Breadth in Children Who Are Hard of Hearing

Purpose Children who are hard of hearing (CHH) tend to have reduced vocabularies compared to children with normal hearing (CNH). Prior research on vocabulary skills in children with hearing loss has focused primarily on their breadth of knowledge (how many words are known). Depth of vocabulary knowledge (how well words are known) is not well documented for CHH. The current study used linear mixed models (LMMs) to investigate growth trajectories of vocabulary depth and breadth in CHH relative to age-matched CNH. Method Participants for this study included 155 children (93 CHH, 62 CNH) enrolled in a longitudinal study. Examiners administered a standardized measure of vocabulary knowledge at ages 7, 8, and 9 years. We constructed multiple LMMs with fixed effects for group and age. The models included various combinations of random intercepts for subject and item and random slope for age. Results For depth, CHH showed significant and stable deficits compared to CNH over time. For breadth, CNH showed greater vocabulary breadth, but the group differences diminished with age. For CHH, higher aided audibility, age, and maternal educational level were associated with greater vocabulary breadth and depth. Age at hearing aid fitting was not. Conclusions A major advantage of using LMM is that it allowed us to cope with missing data points while still accounting for variability within and across participants. Assessment of both vocabulary breadth and depth may be useful in identifying school-age CHH who are at risk of delays in language outcomes.

Unilateral congenital hearing loss in children: Challenges and potentials

The estimated incidence of sensorineural hearing impairment (>40 dB HL) at birth is 1.86 per 1000 newborns in developed countries and 30-40% of these are unilateral. Profound sensorineural unilateral hearing impairment or single sided deafness (SSD) can be treated with a cochlear implant. However, this treatment is costly and invasive and unnecessary in the eyes of many. Very young children with SSD often do not exhibit language and cognitive delays and it is hard to imagine that neurocognitive skills will present difficulties with one good ear. In the current paper we review the most recent evidence on the consequences of unilateral hearing impairment for auditory and neurocognitive factors. While data of both adults and children are discussed, we focus on developmental factors, congenital deafness and a window of opportunity for intervention. We discuss which etiologies qualify for a cochlear implant and present our multi-center prospective study on cochlear implants in infants with one deaf ear. The large, state-of-the art body of research allows for evidence-based decisions regarding management of unilateral hearing loss in children.

What Clinicians Need to Know About Early Literacy Development in Children With Hearing Loss

Purpose Children with hearing loss may not reach the same level of reading proficiency as their peers with typical development. Audiologists and speech-language pathologists (SLPs) have important roles to play in preventing this problem early in children's development. In this tutorial, we aim to communicate how the habilitation practices of audiologists and intervention services of SLPs can support early literacy skill development in children with hearing loss. Method We describe key findings from peer-reviewed research articles to provide a review of early literacy skill development, to explain the relationship between early literacy skills and conventional reading skills, and to highlight findings from early literacy skill intervention studies that included children with hearing loss who use spoken language. We conclude with a hypothetical case study to illustrate how audiologists and SLPs can support early literacy acquisition in children with hearing loss. Conclusion Findings from studies of young children with hearing loss suggest that a promising approach to improving reading outcomes is to provide explicit early literacy instruction and intervention.

Relationship of Grammatical Context on Children's Recognition of s/z-Inflected Words

BACKGROUND

Access to aided high-frequency speech information is currently assessed behaviorally using recognition of plural monosyllabic words. Because of semantic and grammatical cues that support word+morpheme recognition in sentence materials, the contribution of high-frequency audibility to sentence recognition is less than that for isolated words. However, young children may not yet have the linguistic competence to take advantage of these cues. A low-predictability sentence recognition task that controls for language ability could be used to assess the impact of high-frequency audibility in a context that more closely represents how children learn language.

PURPOSE

To determine if differences exist in recognition of s/z-inflected monosyllabic words for children with normal hearing (CNH) and children who are hard of hearing (CHH) across stimuli context (presented in isolation versus embedded medially within a sentence that has low semantic and syntactic predictability) and varying levels of high-frequency audibility (4- and 8-kHz low-pass filtered for CNH and 8-kHz low-pass filtered for CHH).

RESEARCH DESIGN

A prospective, cross-sectional design was used to analyze word+morpheme recognition in noise for stimuli varying in grammatical context and high-frequency audibility. Low-predictability sentence stimuli were created so that the target word+morpheme could not be predicted by semantic or syntactic cues. Electroacoustic measures of aided access to high-frequency speech sounds were used to predict individual differences in recognition for CHH.

STUDY SAMPLE

Thirty-five children, aged 5-12 yrs, were recruited to participate in the study; 24 CNH and 11 CHH (bilateral mild to severe hearing loss) who wore hearing aids (HAs). All children were native speakers of English.

DATA COLLECTION AND ANALYSIS

Monosyllabic word+morpheme recognition was measured in isolated and sentence-embedded conditions at a +10 dB signal-to-noise ratio using steady state, speech-shaped noise. Real-ear probe microphone measures of HAs were obtained for CHH. To assess the effects of high-frequency audibility on word+morpheme recognition for CNH, a repeated-measures ANOVA was used with bandwidth (8 kHz, 4 kHz) and context (isolated, sentence embedded) as within-subjects factors. To compare recognition between CNH and CHH, a mixed-model ANOVA was completed with context (isolated, sentence-embedded) as a within-subjects factor and hearing status as a between-subjects factor. Bivariate correlations between word+morpheme recognition scores and electroacoustic measures of high-frequency audibility were used to assess which measures might be sensitive to differences in perception for CHH.

RESULTS

When high-frequency audibility was maximized, CNH and CHH had better word+morpheme recognition in the isolated condition compared with sentence-embedded. When high-frequency audibility was limited, CNH had better word+morpheme recognition in the sentence-embedded condition compared with the isolated condition. CHH whose HAs had greater high-frequency speech bandwidth, as measured by the maximum audible frequency, had better word+morpheme recognition in sentences.

CONCLUSIONS

High-frequency audibility supports word+morpheme recognition within low-predictability sentences for both CNH and CHH. Maximum audible frequency can be used to estimate word+morpheme recognition for CHH. Low-predictability sentences that do not contain semantic or grammatical context may be of clinical use in estimating children's use of high-frequency audibility in a manner that approximates how they learn language.

Exploring Cascading Effects of Multimodal Communication Skills in Infants With Hearing Loss

Infants and toddlers with hearing loss (HL) are at risk for developing communicative delays that can have a substantial lasting effect. Understanding child characteristics that may be targeted in early intervention is essential to maximizing communicative outcomes in children with HL. Among the most malleable predictors of communication skills include maternal responsivity, gestures, and vocalizations. The purpose of this study was to examine the relationship among maternal responsivity, prelinguistic communication skills and expressive vocabulary in children with HL. Based upon the results we propose a theoretical cascading model of communicative outcomes for children with HL such that gesture use may be associated with future vocalizations which may in turn be related to long-term spoken language outcomes. This exploratory model may be supported by the underlying transactional model of bidirectional language development that occurs through maternal sensitivity in the first two years of life. Additionally, parents of children with HL may be less likely to respond to a single mode of communication than to a combination of modes. This exploratory study provides a theoretical framework by which multimodal communication development in infants and toddlers with HL may be better understood, and suggests hypotheses for future research and implications for intervention practice.

Spoken language and everyday functioning in 5-year-old children using hearing aids or cochlear implants

OBJECTIVE

This study investigated the factors influencing 5-year language, speech and everyday functioning of children with congenital hearing loss.

DESIGN

Standardised tests including PLS-4, PPVT-4 and DEAP were directly administered to children. Parent reports on language (CDI) and everyday functioning (PEACH) were collected. Regression analyses were conducted to examine the influence of a range of demographic variables on outcomes.

STUDY SAMPLE

Participants were 339 children enrolled in the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study.

RESULTS

Children's average receptive and expressive language scores were approximately 1 SD below the mean of typically developing children, and scores on speech production and everyday functioning were more than 1 SD below. Regression models accounted for 70-23% of variance in scores across different tests. Earlier CI switch-on and higher non-verbal ability were associated with better outcomes in most domains. Earlier HA fitting and use of oral communication were associated with better outcomes on directly administered language assessments. Severity of hearing loss and maternal education influenced outcomes of children with HAs. The presence of additional disabilities affected outcomes of children with CIs.

CONCLUSIONS

The findings provide strong evidence for the benefits of early HA fitting and early CI for improving children's outcomes.

Language Development and Impairment in Children With Mild to Moderate Sensorineural Hearing Loss

PURPOSE

The goal of this study was to examine language development and factors related to language impairments in children with mild to moderate sensorineural hearing loss (MMHL).

METHOD

Ninety children, aged 8-16 years (46 children with MMHL; 44 aged-matched controls), were administered a battery of standardized language assessments, including measures of phonological processing, receptive and expressive vocabulary and grammar, word and nonword reading, and parental report of communication skills. Group differences were examined after controlling for nonverbal ability.

RESULTS

Children with MMHL performed as well as controls on receptive vocabulary and word and nonword reading. They also performed within normal limits, albeit significantly worse than controls, on expressive vocabulary, and on receptive and expressive grammar, and worse than both controls and standardized norms on phonological processing and parental report of communication skills. However, there was considerable variation in performance, with 26% showing evidence of clinically significant oral or written language impairments. Poor performance was not linked to severity of hearing loss nor age of diagnosis. Rather, outcomes were related to nonverbal ability, maternal education, and presence/absence of family history of language problems.

CONCLUSIONS

Clinically significant language impairments are not an inevitable consequence of MMHL. Risk factors appear to include lower maternal education and family history of language problems, whereas nonverbal ability may constitute a protective factor.

Concern for Others: A Study on Empathy in Toddlers with Moderate Hearing Loss

Empathy, the ability to feel the emotions of others and respond affectively to these emotions, is an important factor in the development of social competence. The purpose of this study was to examine empathy levels in toddlers with moderate hearing loss (MHL) compared to toddlers with no hearing loss (nHL), and to explore the relation between language ability and empathy. We focused on affective empathy and the precursors of cognitive empathy. A total of 23 toddlers with MHL and 21 toddlers with nHL participated in the study. Parent report (ITSEA) and observation measures were used to rate the toddlers' levels of empathy. The results showed that the levels of affective empathy in toddlers with MHL and with nHL were similar on both measures. Toddlers with MHL lagged behind their peers with nHL on some precursors of cognitive empathy (intention understanding and joint attention). Language ability was unrelated to empathy levels in both groups of toddlers. In conclusion, toddlers with MHL seem to be at risk for problems in their empathy development. Although they are aware of the emotions of others, the development of more complex skills needed for an adequate empathic response is delayed in comparison with their hearing peers.

Service Delivery to Children With Mild Hearing Loss: Current Practice Patterns and Parent Perceptions

PURPOSE

This study investigates clinical practice patterns and parent perception of intervention for children with mild hearing loss (HL).

METHOD

Ages at and delays between service delivery steps (first diagnostic evaluation, confirmation of HL, hearing aid [HA] fitting, entry into early intervention) were investigated for 113 children with mild HL. Comparisons were made to children with moderate-to-severe HL. Parents of children with mild HL reported reasons for delays and their perceptions of intervention and amplification for their children.

RESULTS

Seventy-four percent of children with mild HL were identified through the newborn hearing screen; 26% were identified later due to passing or not receiving a newborn hearing screen. Ninety-four percent of children with mild HL were fit with HAs, albeit at significantly later ages than children with moderate-to-severe HL. Most parents indicated that their children benefited from HA use, but some parents expressed ambivalence toward the amount of benefit.

CONCLUSIONS

Audiologists appear to be moving toward regularly providing amplification for children with mild HL. However, delays in HA fittings indicate that further educating professionals and parents about the benefits of early amplification and intervention is warranted to encourage timely fitting and consistent use of HAs.

Technology-assisted language intervention for children who are deaf or hard-of-hearing; a pilot study of augmentative and alternative communication for enhancing language development

PURPOSE

Pilot study to assess the effect of augmentative and alternative communication technology to enhance language development in children who are deaf or hard-of-hearing.

MATERIALS AND METHODS

Five children ages 5-10 years with permanent bilateral hearing loss who were identified with language underperformance participated in an individualized 24-week structured program using the application TouchChat WordPower on iPads^®. Language samples were analyzed for changes in mean length of utterance, vocabulary words and mean turn length. Repeated measures models assessed change over time.

RESULTS

The baseline median mean length of utterance was 2.41 (range 1.09-6.63; mean 2.88) and significantly increased over time (p = 0.002) to a median of 3.68 at final visit (range 1.97-6.81; mean 3.62). At baseline, the median total number of words spoken per language sample was 251 (range 101-458), with 100 (range 36-100) different words spoken. Total words and different words significantly increased over time (β = 26.8 (7.1), p = 0.001 for total words; β = 8.0 (2.7), p = 0.008 for different words). Mean turn length values also slightly increased over time.

CONCLUSIONS

Using augmentative and alternative communication technology on iPads^® shows promise in supporting rapid language growth among elementary school-age children who are deaf or hard-of-hearing with language underperformance.

Trends and Predictors of Longitudinal Hearing Aid Use for Children Who Are Hard of Hearing

OBJECTIVES

Children who are hard of hearing (CHH) have restricted access to acoustic and linguistic information. Increased audibility provided by hearing aids (HAs) influences language outcomes, but the advantages of appropriately fit HAs can only be realized if children wear their devices on a consistent basis. The purpose of this article was to characterize long-term HA use in CHH, based on parent-report measures, and identify factors that influence longitudinal trends in HA use.

DESIGN

Participants were parents of 290 children with mild to severe hearing loss. At every visit, parents estimated the average amount of time the child used HAs per day during the week and on the weekends. Parent reports of daily HA use were analyzed to determine if different patterns of HA use were observed longitudinally during the study. Independent predictor variables were then related to longitudinal trends in HA use within three age groups (infant, preschool, school age).

RESULTS

On average across multiple visits, parents reported that their children wore their HAs for 10.63 hr per day (SD = 3.29). Data logging values were lower than parent-report measures (M = 8.44, SD = 4.06), suggesting that parents overestimated daily HA use. The majority of children in each age group wore HAs at least 8 hr per day from their first research testing interval to their last, based on parent-report measures. Maternal education level predicted longitudinal trends in HA use for infants and school-age CHH. Degree of hearing loss was related to trends in school-age children only.

CONCLUSIONS

These results indicated that the majority of CHH increased HA use over time, but a sizable minority demonstrated a low level of use or decreased use in the time period studied. Maternal education level influenced longitudinal trends in daily HA use. Degree of hearing loss influenced trends in school-age children only. Audiologists and early intervention service providers might aid in improving HA use by providing regular hands-on training with the HAs and individualized problem-based strategies to address the challenges families experience with attaining a high level of use. Families may also benefit from practical demonstrations of the benefits of consistent HA use, such as hearing loss simulations, examples of listening in noise with and without HAs, or listening to malfunctioning HAs.

Language Outcomes in Young Children with Mild to Severe Hearing Loss

OBJECTIVES

This study examined the language outcomes of children with mild to severe hearing loss during the preschool years. The longitudinal design was leveraged to test whether language growth trajectories were associated with degree of hearing loss and whether aided hearing influenced language growth in a systematic manner. The study also explored the influence of the timing of hearing aid fitting and extent of use on children's language growth. Finally, the study tested the hypothesis that morphosyntax may be at particular risk due to the demands it places on the processing of fine details in the linguistic input.

DESIGN

The full cohort of children in this study comprised 290 children who were hard of hearing (CHH) and 112 children with normal hearing who participated in the Outcomes of Children with Hearing Loss (OCHL) study between the ages of 2 and 6 years. CHH had a mean better-ear pure-tone average of 47.66 dB HL (SD = 13.35). All children received a comprehensive battery of language measures at annual intervals, including standardized tests, parent-report measures, and spontaneous and elicited language samples. Principal components analysis supported the use of a single composite language score for each of the age levels (2, 3, 4, 5, and 6 years). Measures of unaided (better-ear pure-tone average, speech intelligibility index) and aided (residualized speech intelligibility index) hearing were collected, along with parent-report measures of daily hearing aid use time. Mixed modeling procedures were applied to examine the rate of change (227 CHH; 94 children with normal hearing) in language ability over time in relation to (1) degree of hearing loss, (2) aided hearing, (3) age of hearing aid fit and duration of use, and (4) daily hearing aid use. Principal components analysis was also employed to examine factor loadings from spontaneous language samples and to test their correspondence with standardized measures. Multiple regression analysis was used to test for differential effects of hearing loss on morphosyntax and lexical development.

RESULTS

Children with mild to severe hearing loss, on average, showed depressed language levels compared with peers with normal hearing who were matched on age and socioeconomic status. The degree to which CHH fell behind increased with greater severity of hearing loss. The amount of improved audibility with hearing aids was associated with differential rates of language growth; better audibility was associated with faster rates of language growth in the preschool years. Children fit early with hearing aids had better early language achievement than children fit later. However, children who were fit after 18 months of age improved in their language abilities as a function of the duration of hearing aid use. These results suggest that the language learning system remains open to experience provided by improved access to linguistic input. Performance in the domain of morphosyntax was found to be more delayed in CHH than their semantic abilities.

CONCLUSION

The data obtained in this study largely support the predictions, suggesting that mild to severe hearing loss places children at risk for delays in language development. Risks are moderated by the provision of early and consistent access to well-fit hearing aids that provide optimized audibility.

Speech Recognition and Parent Ratings From Auditory Development Questionnaires in Children Who Are Hard of Hearing

OBJECTIVES

Progress has been made in recent years in the provision of amplification and early intervention for children who are hard of hearing. However, children who use hearing aids (HAs) may have inconsistent access to their auditory environment due to limitations in speech audibility through their HAs or limited HA use. The effects of variability in children's auditory experience on parent-reported auditory skills questionnaires and on speech recognition in quiet and in noise were examined for a large group of children who were followed as part of the Outcomes of Children with Hearing Loss study.

DESIGN

Parent ratings on auditory development questionnaires and children's speech recognition were assessed for 306 children who are hard of hearing. Children ranged in age from 12 months to 9 years. Three questionnaires involving parent ratings of auditory skill development and behavior were used, including the LittlEARS Auditory Questionnaire, Parents Evaluation of Oral/Aural Performance in Children rating scale, and an adaptation of the Speech, Spatial, and Qualities of Hearing scale. Speech recognition in quiet was assessed using the Open- and Closed-Set Test, Early Speech Perception test, Lexical Neighborhood Test, and Phonetically Balanced Kindergarten word lists. Speech recognition in noise was assessed using the Computer-Assisted Speech Perception Assessment. Children who are hard of hearing were compared with peers with normal hearing matched for age, maternal educational level, and nonverbal intelligence. The effects of aided audibility, HA use, and language ability on parent responses to auditory development questionnaires and on children's speech recognition were also examined.

RESULTS

Children who are hard of hearing had poorer performance than peers with normal hearing on parent ratings of auditory skills and had poorer speech recognition. Significant individual variability among children who are hard of hearing was observed. Children with greater aided audibility through their HAs, more hours of HA use, and better language abilities generally had higher parent ratings of auditory skills and better speech-recognition abilities in quiet and in noise than peers with less audibility, more limited HA use, or poorer language abilities. In addition to the auditory and language factors that were predictive for speech recognition in quiet, phonological working memory was also a positive predictor for word recognition abilities in noise.

CONCLUSIONS

Children who are hard of hearing continue to experience delays in auditory skill development and speech-recognition abilities compared with peers with normal hearing. However, significant improvements in these domains have occurred in comparison to similar data reported before the adoption of universal newborn hearing screening and early intervention programs for children who are hard of hearing. Increasing the audibility of speech has a direct positive effect on auditory skill development and speech-recognition abilities and also may enhance these skills by improving language abilities in children who are hard of hearing. Greater number of hours of HA use also had a significant positive impact on parent ratings of auditory skills and children's speech recognition.

Parental stress among parents of toddlers with moderate hearing loss

BACKGROUND

The purpose of this study was to examine parental stress in parents of toddlers with moderate hearing loss compared to hearing controls. Furthermore, the associations between parental stress and child- and parent-related factors such as language, social-emotional functioning and social support were examined.

DESIGN

The study sample consisted of 30 toddlers with moderate hearing loss and 30 hearing children (mean age 27.4 months). The two groups were compared using the Nijmegen Parenting Stress Index (NPSI) and parent-reports to rate the amount of social support and the children's social-emotional functioning. Receptive and expressive language tests were administered to the children to examine their language ability.

RESULTS

Parents of toddlers with moderate hearing loss reported comparable levels of parental stress to parents of hearing children. Individual differences in parental stress were related to child- and parent-related factors. Poorer social-emotional functioning and language ability of the child were related to higher stress levels in parents. Parents who experienced less social support reported higher stress levels.

CONCLUSIONS

Parents of toddlers with moderate hearing loss experience no more parental stress than parents of hearing children on average. Given parental stress was found to be related to poorer child functioning, early interventionists should be aware of signs of elevated stress levels in parents.

New language outcome measures for Mandarin speaking children with hearing loss

Objective

The paper discusses recent evidence on the assessment of language outcomes in children with hearing loss acquiring oral language.

Methods

Research emphasizes that language tests must be specific enough to capture subtle deficits in vocabulary and grammar learning at different developmental ages. The Diagnostic Receptive and Expressive Assessment of Mandarin (DREAM) was carefully designed to be a comprehensive standardized Mandarin assessment normed in Mainland China.

Results

This paper summarizes the evidence-based item design process and validity and reliability results of DREAM. A pilot study reported here shows that DREAM provided detailed information about hearing impaired children's language abilities and can be used to aid intervention planning to maximize progress.

Conclusion

DREAM represents an example of translational science, transferring methods from empirical studies of language acquisition in research environments into applied domains such as assessment and intervention. Research on outcomes in China will advance significantly with the availability of evidence-based comprehensive language tests that measure a sufficient age range of skills, are normed on Mandarin speaking children in mainland China, and are designed to capture features central to Mandarin language acquisition.

The impact of degree of hearing loss on auditory brainstem response predictions of behavioral thresholds

OBJECTIVES

Diagnosis of hearing loss and prescription of amplification for infants and young children require accurate estimates of ear- and frequency-specific behavioral thresholds based on auditory brainstem response (ABR) measurements. Although the overall relationship between ABR and behavioral thresholds has been demonstrated, the agreement is imperfect, and the accuracy of predictions of behavioral threshold based on ABR may depend on degree of hearing loss. Behavioral thresholds are lower than ABR thresholds, at least in part due to differences in calibration interacting with the effects of temporal integration, which are manifest in behavioral measurements but not ABR measurements and depend on behavioral threshold. Listeners with sensory hearing loss exhibit reduced or absent temporal integration, which could impact the relationship between ABR and behavioral thresholds as degree of hearing loss increases. The present study evaluated the relationship between ABR and behavioral thresholds in infants and children over a range of hearing thresholds, and tested an approach for adjusting the correction factor based on degree of hearing loss as estimated by ABR measurements.

DESIGN

A retrospective review of clinical records was completed for 309 ears of 177 children with hearing thresholds ranging from normal to profound hearing loss and for whom both ABR and behavioral thresholds were available. Children were required to have the same middle ear status at both evaluations. The relationship between ABR and behavioral thresholds was examined. Factors that potentially could affect the relationship between ABR and behavioral thresholds were analyzed, including degree of hearing loss observed on the ABR, behavioral test method (visual reinforcement, conditioned play, or conventional audiometry), the length of time between ABR and behavioral assessments, and clinician-reported reliability of the behavioral assessment. Predictive accuracy of a correction factor based on the difference between ABR and behavioral thresholds as a function of ABR threshold was compared to the predictive accuracy achieved by two other correction approaches in current clinical use.

RESULTS

As expected, ABR threshold was a significant predictor of behavioral threshold. The agreement between ABR and behavioral thresholds varied as a function of degree of hearing loss. The test method, length of time between assessments, and reported reliability of the behavioral test results were not related to the differences between ABR and behavioral thresholds. A correction factor based on the linear relationship between the differences in ABR and behavioral thresholds as a function of ABR threshold resulted in more accurately predicted behavioral thresholds than other correction factors in clinical use.

CONCLUSIONS

ABR is a valid predictor of behavioral threshold in infants and children. A correction factor that accounts for the effect of degree of hearing loss on the differences between ABR and behavioral thresholds resulted in more accurate predictions of behavioral thresholds than methods that used a constant correction factor regardless of degree of hearing loss. These results are consistent with predictions based on previous research on temporal integration for listeners with hearing loss.

The Influence of Hearing Aid Use on Outcomes of Children With Mild Hearing Loss

PURPOSE

This study examined the effects of consistent hearing aid (HA) use on outcomes in children with mild hearing loss (HL).

METHOD

Five- or 7-year-old children with mild HL were separated into 3 groups on the basis of patterns of daily HA use. Using analyses of variance, we compared outcomes between groups on speech and language tests and a speech perception in noise task. Regression models were used to investigate the influence of cumulative auditory experience (audibility, early intervention, HA use) on outcomes.

RESULTS

Full-time HA users demonstrated significantly higher scores on vocabulary and grammar measures compared with nonusers. There were no significant differences between the 3 groups on articulation or speech perception measures. After controlling for the variance in age at confirmation of HL, level of audibility, and enrollment in early intervention, only amount of daily HA use was a significant predictor of grammar and vocabulary.

CONCLUSIONS

The current results provide evidence that children's language development benefits from consistent HA use. Nonusers are at risk in areas such as vocabulary and grammar compared with other children with mild HL who wear HAs regularly. Service providers should work collaboratively to encourage consistent HA use.