Family-centered early intervention for families and children who are deaf or hard of hearing Christine Yoshinaga-Itano, Ph.D. University of Colorado, Boulder
Best Practice Matters Family-centered early intervention is important Institute best practice guidelines for screening, audiologic diagnostic evaluations, amplification fitting, medical intervention and early intervention services Develop system of accountability, training and professional development
Intervention Matters Systems development that assures screening by 1 month, diagnosis by 3 months, amplification within a month of diagnosis, early intervention services by 6 months First contact and early intervention follow-through is delivered by professionals with specialty knowledge and skills in deafness and hearing loss, parent-infant intervention and developmentally appropriate practices.
Intervention Matters Monitor development every 6 months to assure families that early intervention strategies have the intended outcomes. A state-nationprovince -wide/ consistent protocol allows identification of system strengths and weaknesses Develop regular and consistent in-service education for early intervention providers through workshops, consultation, and direct observations
Intervention Matters Infuse professionals who are deaf and hard of hearing at all levels of the system. Parent-to-parent leadership partners with early intervention providers at every step in the process. (Hands and Voices Guide By Your Side) Develop and implement parent surveys are used to monitor the quality of the program Assure that intervention decisions are datadriven and efficacy based
Highest quality of auditory/visual communication Sign language instruction offered by fluent/native signers (deaf/hard of hearing) Listening and spoken language intervention offered by professionals with excellent skills and knowledge in the development of spoken language for children who are deaf or hard of hearing
Outcomes of children who are deaf or hard of hearing after universal newborn hearing screening Christine Yoshinaga-Itano, Ph.D. Professor University of Colorado, Boulder Department of Speech, Language & Hearing Sciences Marion Downs Hearing Center
Longitudinal study: Number of children with hearing loss identified between 1997-2003 65-70% of all possible participants Infants identified with hearing loss in Colorado Born 1997 through 2003 All birthing hospitals in Colorado established universal newborn hearing screening programs by 1999
What are the characteristics for optimal outcomes? For children with normal cognitive development: Similar distributions for expressive and receptive language development Intelligible speech production Ability to receive instruction in a typical classroom with the same expectations as hearing peers Optimal outcomes regardless of degree of hearing loss or maternal level of education
Mean Language Age Expressive Vocabulary (EOWPVT) 90 80 70 hearing d/hoh 60 50 40 30 20 48 60 72 84 Chronological Age (months) Sedey & Yoshinaga-Itano, 2008
Mean Language Age Vocabulary Comprehension (TACL) 100 90 80 70 hearing d/hoh 60 50 40 30 20 48 60 72 84 Chronological Age (months) Sedey & Yoshinaga-Itano, 2008
Mean Language Age Comprehension of Grammar (TACL) 90 80 70 60 50 40 30 20 hearing d/hoh 48 60 72 84 Chronological Age (months) Sedey & Yoshinaga-Itano, 2008
Mean Language Age Comprehension of Elaborated Sentences (TACL) 90 80 70 60 50 40 30 20 hearing d/hoh 48 60 72 84 Chronological Age (months) Sedey & Yoshinaga-Itano, 2008
DO INDIVIDUAL CHILD CHARACTERISTICS SYSTEMATICALLY DIFFERENTIATE THE LANGUAGE TRAJECTORIES IN YOUNG CHILDREN WITH HEARING LOSS FROM BIRTH TO 36 MONTHS?
Longitudinal study: birth through 84 months- Baca, Yoshinaga-Itano, Sedey (2011) N=146 Birth cohort: 1997-2005 Non-verbal cognitive ability normal range One or more early intervention assessment Normal hearing English primary language Bilateral permanent HL, excluding auditory neuropathy No other significant disabilities Residents of state of Colorado
Children with severe to profound HL: 48 to 87 mo. N= 87 had severe to profound HL Children with cochlear implants (N=49) Age of ID by 6 months: 55% Age of ID by 12 months: 86% Children with hearing aids (N=35) Age of ID by 6 months: 68.4% Age of ID by 12 months: 76% N=48 had mild to moderate HL
Variability in outcome at 84 months: EOWPVT, TACL (Baca et al., 2011) 68% of variability in EOWPVT age score at 84 months explained 71% of variability in TACL age score at 84 months explained Frequency of parent words Maternal level of education Early expressive language quotient Degree of hearing loss Age of identification Non-verbal IQ
Growth rate variability (Baca et al., 2011) 46% of growth rate of EOWPVT 81% of growth rate of TACL age score Predictors of expressive vocabulary Maternal level of education Progressive HL Non-verbal IQ Predictors of language comprehension Age of ID Progressive HL Non-verbal IQ
Maternal word frequency: language outcome at 84 mo. (Baca, et al., 2011) Maternal word frequency accounted for: 12% variability EOWPVT score at 84 mo. 16% variability TACL score at 84 mo. Children with word frequency count in the upper quartile (>=1515) had a 29.6 mo. advantage on EOWPVT and 15 mo. advantage on the TACL When compared to parents in the lower quartile (<=984). Parents of our DHH children had double the word frequency rate if half-hour videotape rates prorated to daily frequency.
Maternal word frequency: rate of language growth (Baca et al., 2011) +11.5 months on language growth on EOWPVT +9.6 months on language growth on TACL
Severe HL: outcome at 84 mo. (Baca, et al., 2011) -17.74 in expressive vocabulary score -9.49 in language comprehension score Relative to other HL categories **(severe HL category had a lower maternal level of education than profound HL)
ID by 3 mo: outcome at 84 mo. (Baca et al., 2011) +10.21 mo. Difference for EOWPVT +4.84 mo. Difference for TACL
Non-verbal cognitive: Leiter (outcome at 84 mo.) (Baca et al., 2011) Difference in 10 points on Leiter International Performance Scale resulted in +6.7 month difference in EOWPVT age score +5.7 month difference in TACL age score
Maternal level of education 16 or more years (Baca et al., 2011) +15.25 mo. difference at 84 mo. of age EOWPVT +7.43 mo. Difference at 84 mo. Of age TACL
Child Development Inventory: Expressive Language >80 (outcome at 84 mo.) (Baca, et al., 2011) +8.09 mo. Difference on EOWPVT age score No difference on TACL age score
Maternal level of education and other socio-economic factors-0-36 mo. Colorado studies indicate that Maternal level of education does not predict language outcomes of children with hearing loss birth through 36 months We now know it is because early intervention is successful in optimal language access regardless of maternal level of education.
EOWPVT differences by Maternal Level of Educational Level (Baca, 2009) Below HS vs. College degree + Unfortunately, for the parents with the lowest levels of education there was a 35 month language age difference at 84 months of age between group with mean age level for mothers with educational level less than 12 years (HS grad) as compared to group for mothers with educational level 16 years or greater (college) 55.75 months versus 91.33 months
MCDI-EL and TACL-3 (Baca, 2009)
Guiding Principles Bringing back the joy of parenthood that diagnosis of hearing loss impacted- focus on emotional availability of parent to child and child to parent Emotional-availability of parent-child dyads similar to hearing dyads Parental Stress levels have same distribution as norming population Conversational strategies re: turn-taking ratios are similar to hearing dyads
CO Parent survey: Audiology and EI Services 95% of families are satisfied with their audiologists experience and services. 88% of families are satisfied with their early intervention services. 85% felt the communication options given were unbiased.
Parental Stress is highly related to language outcomes It is important that early intervention programs result in similar stress levels to hearing children and their parents No significant difference with hearing norms: on Difficult Child subscale or Parent-Child Dysfunctional Interaction Hearing mothers of children with hearing loss in CHIP reported lower levels of Parental Distress than mothers in the normative sample, even when 40% of the sample of mothers with children who had hearing loss were multiply disabled
Clinical cut-off 13% of the parents of this sample scored at or above the clinical cut-off (40% multiply disabled) Abidin reports the 90 th %ile as the clinical cut-off
PRAGMATIC LANGUAGE CHARACTERISTICS
Presentation Overview Background Pragmatic skill development Methods Results Normal hearing data Compare pragmatic skills of children with and without hearing loss Conclusions Future Directions
Research Questions When do children with hearing loss master specific pragmatic skills in comparison to their peers with normal hearing? How does development differ based on degree of hearing loss?
Pragmatics Social Language Use ASHA Website: Using language for different purposes Changing language according to the needs of a listener or situation Following rules for conversations and storytelling
Pragmatics Pragmatic language difficulties increase risk for victimization (Conti-Ramsden & Botting, 2004). Pragmatic difficulties increase risk for social and emotional deficits (Ketelaars, et al., 2009)
Hearing Loss and Pragmatics Children who are deaf or hard of hearing use more directive and less informative communicative functions than their normally hearing age-matched peers (Day, 1986; Nicholas, 2000; Nicholas & Geers, 1997)
Normal Hearing Group: Data Collection Pragmatics Checklist Goberis, D., 1999, adapted from work done by Simon, C.S., 1984. Online version of Pragmatics Checklist created on SurveyMonkey Solicited participants: Posted on Hand and Voices website Through E-mail
Hearing Loss Group: Data Collection U.S. Dept. of Education Office of Education #H325D030031A, H324C030074 supported research project on language acquisition of children with hearing loss Parents completed a printed version of the Pragmatics Checklist Children were re-assessed annually
The Pragmatic Checklist (Goberis, D., 1999) 45 items Parents are asked to indicate whether or not a skill is present by selecting from the following choices: Not present Preverbal 1-3 words Complex language
Study Participants Normal Hearing Group N=109 Age Range: 2-7 years Normal hearing and cognition Hearing Loss Group N=126 Age Range: 3-7 years All Levels of hearing loss Normal cognition
Study Participants Children in both groups were determined to have normal cognition Normal hearing group: based on parent report Hearing loss group: IQ 70 on the Leiter non-verbal intelligence test
Demographics: Gender
Age Years Age Range (Months) 2 Years 1;6-2;5 years (18-29 months) 3 Years 2;6-3;5 years (30-41 months) 4 years 3;6-4;5 years (42-53 months) 5 years 4;6-5;5 years (54-65 months) 6 years 5;6-6;5 years (66-77 months) 7 years 6;6-7;5 years (78-89 months) 8 years 7;6 + years (90+ months)
Demographics: Age
Demographics: Maternal Level of Education
Demographics: Ethnicity
Demographics: Languages Spoken
Demographics: Degree of Hearing Loss
Mastery Criterion Children in age groups were determined to have mastered a skill with use of complex language when 75% of the children achieved the skill.
Children with Normal Hearing 44% (20 of 45) of the items were mastered using complex language by 3 years of age 95.5% (43 of 45) of the items were mastered by 4 years of age 98% by 5 years 100% by 6 years
Final Items to Master for NH group Provides information on request Name, date of birth, address (2 of 3 items) Makes promises
Children with Hearing Loss 6.6% (3 of 45) of the items were mastered with complex language by six years of age 69% (31 of 45) of the items were mastered by 7 years of age
Earliest Items to Master (HL Group) Makes polite requests Uses words: please, thank you. Expresses needs Role plays with props
Items not Mastered by 7yrs (HL Group) Provides information on request Repairs incomplete sentences Ends conversations Interjects Apologies Request clarification Makes promises Ask questions to problem solve
Items not mastered by 75% of the children at 7 years of age Asks questions to make predictions Retells a story Tells 4-6 picture story in right order Creates original story Explains relationships between objectsaction-situations Compares and contrasts
Percentage of Items Mastered by Age for NH and HL groups
The proportion achieving 50% or more of the items with complex language
Conclusion Children who are deaf or hard of hearing begin to master pragmatic skills at 6 years of age; 3-year-old peers with normal hearing have already mastered nearly half of the checklist skills. By age 7, children who are deaf or hard of hearing have mastered approximately 2/3 of the checklist skills; almost all of the skills are mastered by hearing children by age 4.