A New Chapter. FCEI: Bad Ischl, Austria. Mary Pat Moeller, Ph.D.

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1 1 Children Who are Hard of Hearing A New Chapter FCEI: Bad Ischl, Austria June 1, 2012 Mary Pat Moeller, Ph.D. Boys Town National Research Hospital marypat.moeller@boystown.org

2 Children who are Hard of hearing 2 Described by Julia Davis as Our Forgotten Children For our purposes today Hard of hearing defined as: Children in mild through moderately-severe hearing level range Use hearing aids rather than CIs Reliant primarily on speech and listening for functional communication (Jamieson, 2010)

3 Why called Forgotten Children? 3 Underestimation of needs Limited training of classroom teachers, school personnel Little is known about: Educational achievements Problems faced in regular classrooms Acceptance or non acceptance by peers Extent of support services & impact Poorly monitored amplification Davis, J. (1977)

4 A New Generation A changing population due to: Early identification Improved auditory access Early and effective family-centered programs

5 5 New Chapters

6 6 Chapter 1: For families the path to discovery is different Information is unsolicited and may conflict with observation Delivered e ed at a sensitive s e & potentially vulnerable e time (ASHA, 2008) Family perception of a timetable of development Service delays equated with harm (Young & Tattersall, 2007) Families focus on later outcomes; limited it understanding of preverbal stages/supports (McCracken, et al., 2008) Developmental expectations (Young & Tattersall, 2007)

7 Implications for supporting families: 7 Balance of informational and adjustment counseling (ASHA, 2008) Exercise caution in discussing developmental expectations Sensitivity to affective dimensionsi

8 8 Chapter 2: We need more evidence to support best practice Reduced body of literature concerning children who are HH (Mild and moderately-severe hearing levels) Sample sizes are small or mix D/HH children Lack of control of amplification histories or audibility Few studies attempted a population sample Varied measurement strategies; earlier generation technologies

9 Longitudinal Study of Outcomes J. Bruce Tomblin, Ph.D. and Mary Pat Moeller, Ph.D., PIs Supported by NIDCD R01 DC009560

10 Study design 10 Accelerated Longitudinal Design Each child followed for 3 years+. Retrospective data prior to enrollment obtained by medical record history.

11 Participants Centers HH TH Ages 6 months 6; 11 Boys Town English spoken in the home Iowa No major secondary disabilities North Carolina Permanent Mild to Severe Hearing Loss Total PTA of db HL (500, 1k, 2k, 4 khz) Normally distributed by degree Majority early identified; ~78% fit by 6 months NH cohort matched on SES (income, maternal education)

12 Distribution of Hearing Levels 90 Better ear PTA distribution (db HL) Nu umber of participan nts db db db db db db

13 13 RESULTS: Audiology Factors influencing i follow-up to screening Adequacy of hearing aid fittings Consistency of hearing aid use

14 Follow-Up Age by Maternal Education p =.05 p =.001 High School or less (n=34) Some College (n = 65) Bachelors (n = 50) Post Graduate (n=43) ) Ag ge (months 10 8 p = Age of First Eval Age of Confirmation Intervention Age HA Fitted Holte et al., AJA, accepted

15 Measuring Audibility with HAs: Speech Intelligibility Index (SII) For each band Audibility x FIW = weighted audibility SII = Sum of weighted audibility of all frequency bands RMS Error How closely does the hearing aid gain match a prescribed target?

16 Hearing aid fitting Open symbols = RMS errors > 5 db Filled = RMS errors < 5 db SII >.65 related to better outcomes McCreery, et al., submitted

17 Hearing Aid Fitting by Location 17 McCreery, et al., submitted

18 What variables influence HA use? Maternal education 2 hours more use for college than high school or less Child age Older children > younger children Degree of hearing loss > Better-ear PTA = > use time Listening Situation (car, daycare, public setting)

19 Are parents accurate at estimating average daily hearing aid use time? Parent report = hours Data logging = 8.3 hours Difference = 2.6 hours Range = 2-10 hours Predicted by age -Younger age = larger prediction error 19 Walker et al, LSHSS, in review

20 Summary Maternal education level Predicts Follow-up Hearing aid use Hearing aid fitting errors Despite experienced, confident audiologists On average, parents are generally accurate reporters of hearing aid use Overestimate by an average of 2 hours (Range 2-10 hours) Overestimate by an average of 2 hours (Range 2 10 hours) Use time varies by across different situations Important to ask about consistency of use in varied contexts

21 21 RESULTS: Speech & Language APi Picture of Resilience and Risk

22 Vocabulary Skills at 5 and 7 Years M= p = p = % SS <85

23 Vocabulary: Relationships with Hearing r = -.270, p=.001 r =.414, p =.001 n = 117 n = 88 BEPTA and BESII: r =.792, p <.001 SII >.65 associated with better outcomes (Stiles et al., 2012)

24 Receptive-Expressive Language at 4 Years 140 M = Standa ard Score NH (n=39) HH (n=95) 20 0 Basic Concepts Syntax Pragmatics Composite CASL at Age 4 years ps <.002

25 25 Chapter 3: We need to identify & address areas of development that may be at risk Impact of inconsistent access on structural aspects of language? Phonological skills Morphological development Advanced syntax

26 Word Articulation Scores p =.002 p <.001 p =.018 n=29 n=23 n=15 n=75 n=75 n=36 Standa ard Score NH HH years 5 years 7 years Ages Cross Sectional Results: Goldman-Fristoe Test of Articulation

27 Speech Relationships with Hearing dard Scor re GFTA Stan n = 151 r =.258 r =.360 p =.001 p < Better Ear PTA Better Ear SII BEPTA and BESII: r =.843, p <.001

28 Morphology: Accurate Verb Use 28 Koehlinger, Van Horne, Moeller (in review)

29 Summary 29 On measures of vocabulary and global language skills, mean scores fell within the average range. However, approximately 25-30% of the HH children appeared to be at risk in structural aspects of language: Phonological development Syntax and morphology

30 RESULTS: Psychosocial ldevelopment Risks: Theory of mind Internalizing behaviors 30

31 Theory of Mind Performance at Age 5 years NH pass rate = 90.9%%** HH pass rate = 34.2% NH pass rate = 84%** HH pass rate = 34% Correlated with Syntax r =.546, p =.001 Verbal reasoning r =.563, p = **Chi square = ; p =.001

32 Child Behavior Ratings 32 ps <.05 Higher Scores = Elevated behaviors

33 Summary 33 Further research is needed to understand sources of delays in theory of mind development Advanced syntax? Access to multi-talker conversation? Executive function? Longer term follow-up to determine if internalizing and withdrawal patterns persist for some children

34 34 Chapter 4: Maybe we need to ask some different questions

35 Acoustic Ecology (McKellin, et al., 2007): Need for more focus on accessibility/inaccessibility 35.Need to integrate what is known about the acoustic ecology of childcare and educational settings with the lived experience of the hard of hearing children who inhabit them.

36 Impact of Poor Classroom Acoustics on Hearing Students (McKellin et al., 2007) Acoustic Ecology Project 36 students, grades 1-7, worked at their desks wore oeear-level e e microphones, o so that a stereo eo recording of the noise and conversation at the wearer s ear could be recorded the pragmatics were significantly altered as the level of background noise at ear level increased: e.g., soliloquy and parallel talk, which reflected verbal and social isolation

37 From the Mother of a 4th Grade Girl: a a year or two ago, the children s conversation was less complicated and less rapid-fire, less witty, less all those things. It was easier for her to keep up. And I d say the more she ages, the more she s unable to stay a part of the conversation. So I d say more and more her strategy t is that t she s just leaving and just not bothering. Jamieson, et al., 2009

38 Socialization matters for Learning 38 Quality of social relationships tied to academic progress Learning with friend vs. classmate impacts: Conflict management Deductive reasoning Problem solving Exploration

39 Summary 39 Need to recognize unique and ongoing g family support needs Need for more research focused on children who are hard of hearing Interdisciplinary input In complex listening environments typical of real settings Need to understand impact of noisy contexts on socialization and learning Need for sensitive measures and an integrated view of language, learning and socialization

40 Longitudinal Study Team Members 40 University of Iowa J. Bruce Tomblin, Ph.D. (Co-PI) Marlea O Brien, Program Coordinator Rick Arenas (IT) John Knutson, Ph.D. Ruth Bentler, Ph.D. Lenore Holte, Ph.D. Elizabeth Walker, Ph.D., CCC-A/SLP Connie Ferguson, M.S., CCC-SLP Marcia St. Clair, SLP Examiner Wendy Fick (data entry) Amanda Murray, M.A. Jacob Oleson, Ph.D. (biostatistics) Jane Pendergast, Ph.D. (biostatistics) BTNRH Mary Pat Moeller, Ph.D. (Co-PI) Patricia Stelmachowicz, Ph.D. Ryan McCreery, Ph.D. Meredith Spratford, Au.D. Lauren Berry, M.S., CCC-SLP Emilie Sweet, M.S., CCC-SLP Mark VanDam, Ph.D. (LENA) Sophie Ambrose, Ph.D. (LENA) University of North Carolina-Chapel Hill Melody Harrison, Ph.D. Patricia A. Roush, Au.D. Shana Jacobs, Au.D. M. Thomas Page, M.S., CCC-SLP

41 Thank you! 41 Any questions?