OUTCOMES OF CHILDREN WITH MILD- SEVERE HEARING LOSS: YEAR 3

OUTCOMES OF CHILDREN WITH MILD- SEVERE HEARING LOSS: YEAR 3 SUPPORTED BY NIDCD R01 DC009560 ASHA Convention 2012 ELIZABETH WALKER SOPHIE E. AMBROSE THOMAS A. PAGE

Disclosure 2 We have no relevant financial or nonfinancial relationship(s) within the products or services described, reviewed, evaluated or compared in this presentation.

Goals of this Presentation 3 AUDIOLOGY FINDINGS Follow-up after newborn hearing screen Hearing aid use time Hearing aid fittings STUDY OVERVIEW COMMUNICATION OUTCOMES FINDINGS Speech & language Emergent and early literacy skills Social-cognitive development SERVICE PROVIDER FINDINGS Questionnaire overview Service providers Description of services INCONSISTENT ACCESS HYPOTHESIS PROTECTIVE FACTORS

Study Overview

Background 5 Most outcomes research focused on children who are deaf Challenges with research on children who are hard of hearing: Small sample sizes or inclusion of children who are deaf Did not take amplification history or audibility with hearing aids into account Did not include children in the post-unhs age 2007: National Institutes of Health convened a panel of professionals and researchers who concluded that there is a clear need for prospective research to determine what factors influence success for children who are HH

Background 6 Early language exposure shapes children s linguistic development (Hart & Risley, 1995) Both quantity and quality contribute to auditory-linguistic experience (Huttenlocher et al., 1991; Rideout et al., 2003) Our goal with early amplification is to provide optimal access to language exposure New generation of children Are they achieving expected outcomes? Does inconsistent access lead to risk?

Aims of the OCHL Study 7 To describe the characteristics of: Children who are hard of hearing and their families Intervention services Factors associated with service variations To characterize: Developmental, behavioral, and familial outcomes Performance compared to same-age, hearing peers with similar socio-economic backgrounds Ultimately: How do variations in child and family factors and in intervention characteristics relate to functional outcomes

Study Domains Speech production Language skills Academic abilities Hearing and speech perception Psychosocial and behavioral Background characteristics of child/family Child and Family outcomes Interventions (clinical, audiological, educational)

Our Team 9 J. Bruce Tomblin, Ph.D. (Co-PI) Marlea O Brien, Program Coordinator Rick Arenas, Ph.D. (IT) John Knutson, Ph.D. Ruth Bentler, Ph.D. Lenore Holte, Ph.D. Elizabeth Walker, Ph.D. Connie Ferguson, M.S. Marcia St. Clair, B.A. Wendy Fick (data entry) Jacob Oleson, Ph.D. (biostatistics) Jane Pendergast, Ph.D. (biostatistics) Mary Pat Moeller, Ph.D. (Co-PI) Patricia Stelmachowicz, Ph.D. Ryan McCreery, Ph.D. Sophie Ambrose, Ph.D. Meredith Spratford, Au.D. Lauren Unflat Berry, M.S. Colleen Fitzgerald., M.A. Barbara Peterson (family interviewer) Melody Harrison, Ph.D. Patricia A. Roush, Au.D. Shana Jacobs, Au.D. Thomas A. Page, M.S.

Study participants Inclusion criteria: Ages 6 months to 7 years at entry into study English is primary language spoken in the home No major secondary disabilities No cochlear implant Permanent mild to severe bilateral hearing loss PTA of 25 to 75 db HL in better ear at 500, 1000, 2000, 4000 Hz Sensorineural, mixed, or permanent conductive Current participants 316 children with hearing loss and 120 children with normal hearing, matched by SES and age

SUBJECTS BTNRH UNC IOWA TOTAL HH 121 104 80 305 NH 42 25 53 120

Distribution of Better Ear PTA 12 Number 40 35 30 25 20 15 10 5 0 27 33 39 45 51 57 63 69 75 Mean= 48.69 SD=14.11 PTA

Study Design Each child followed for at least 3 visits. Visits take place at 6, 12 and 18 months, then annually starting at age 2. Retrospective data prior to enrollment obtained by medical record history.

Sources of data Onsite testing of children with parents completing questionnaires BTNRH and UNC-Chapel Hill tested at their medical centers Iowa tested in vans equipped as mobile testing units Additional travel for out of state testing LENA project Language Environment Analysis Subset of 41 children who are HH and 17 children with NH, ages 12 months to 3 years Followed one day per month for one year

Sources of data Annual telephone questionnaire with parents Audiology service provider survey (online) Service provider survey (online) Birth to three Preschool School age Teacher survey Preschool School age Medical records ENT & pediatrician

5 YEAR OLD VISIT (HL) Test Type Test Name Given To Time Primary Responsibility Academic: CTOPP Child 30 minutes SLP TOPEL Print Knowledge Child 10 minutes SLP Speech Production: Goldman Fristoe 2 Child 10 minutes SLP BIT Child 15 minutes SLP Language: PPVT-4 Child 30 minutes SLP PLAI-2 Child 45 minutes SLP Theory of Mind Measures Child 10 minutes SLP CELF-4 Word Structure Subtest Child 15 minutes SLP Hearing Function: Hx, Audiogram (Conventional) + Child 30 minutes Audiologist Tymps Electroacoustic Analysis 60/90 Child 5 minutes Audiologist Psychosocial, Behavioral, & Family: Aided Speech Intelligibility Index Child 15 minutes Audiologist (Verefit SII) PBK Child 15 minutes Audiologist Hearing Aid Checklist Parent 20 minutes Audiologist Adult Perceptions II Parent 20 minutes SLP; Audiologist OCHL Family Interview Parent 60 minutes OCHL SPS Audiology Service 30 minutes Provider OCHL SPS Preschool Service 30 minutes Provider SCBE Teacher 15 minutes SLP; Audiologist

Where are we now? In final year of testing of a 5-year grant cycle Continuing to test participants and collect data Continuing to analyze data through our upper ages Present and Publish findings

Service Provider Findings Questionnaire Overview Service Providers Description of Services Next Steps

Questionnaire Overview Service Provider Surveys Birth to 3, Preschool, & School Age Once each year the child is enrolled in study Online response entry Completion of survey rewarded Birth-3 responses from 118 professionals Further informed by Birth to 3 Family Interview

Service Provision to Children who are Deaf and Hard of Hearing: Birth to 36 months 20 This Joint Committee identified several key areas: Providers of services should have expertise in the areas related to the specific needs of children with all degrees of hearing loss and and their families The services provided should be focused on the family; not simply the child and specified the components that comprise family-centered services. To meet the needs of the wide range of hearing losses that occur and the variety of co-occurring conditions in addition to hearing loss, services should be interdisciplinary. ASHA Council on Education of the Deaf: Technical Report 2008

Professional Identification of Service Providers 21 TOD-HH 47% Audiologist 1% EI Specialist 14% EC-SP Teacher 6% SLP 32%

Professionals Qualifications: Education 22 Degree Make-up 86% 2% 12% Bachelors Only Masters Doctorate

Professionals Qualifications: Education 23 Primary Degree Disciplines 61% 1% 30% 4% 4% Ed. Of deaf/hoh SLP SLP + AUD Early Child Ed Audiology

Professionals Qualifications: Education 24 Certification Beyond Degree Area n=43 ECSE 37% AVT 21% Hanen 2% Sp. Ed 2% ECE 33% PITSTOP 5%

Professionals Qualifications 25 96% reported having certification in the area of employment 60% have completed specialized continuing education in the childhood hearing loss Ranging from half day in-service to multiple semester coursework Experience between 0 and 36 years of EI service 41% with 0 to 5 yrs 17% with 6 to 10 yrs

Cross-section of Specialization 26 Bachelor s degree in Deaf Ed. Local Educational Agency 8 years in EI Half-day in-service Caseload: 50 (3 of which have HL) Master s Degree in SLP State Early Interventionist 15 years in EI Semester course in child HL Caseload: 27 (100% w/ HL) Master s Degree in SLP Private center for children with HL 23 years in EI LSLS Cert. Avt, Hanen Certification Caseload:13 children on caseload (100% w/ HL)

Birth to 3 Caseloads 27 100.0 % of Caseload with HL 90.0 PERCENTAGE 80.0 70.0 60.0 50.0 40.0 n=118 caseload # range= 1-60 caseload mean= 18 % of HL mean= 75.8 % of HL median= 100 30.0 20.0 10.0 0.0 0 10 20 30 40 50 60 70 80 90 100 110 PROVIDERS

Birth to 3 Visits per Month 28 20 18 16 14 n=191 mean = 3 visits /month median = 2 visits/month Average 55.9 minutes a visit VISITS PER MONTH 12 10 8 6 4 2 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 CHILDREN

Site of Early Service Provision 29 Home 86% Txst Office 18% Hospital Clinic 2% Center for Children w HL 25% n=181 Daycare Center 53% EC Center 2% Outside Home

Family Participation by Site 30 Most of the time Half the time or less 95.5% 71.4% 28.6% 4.5% n=181 HOME OUTSIDE OF HOME

Interdisciplinary Nature of Services 31 Multi-Disciplinary Evaluation? Frequency of Communication w/ other providers YES 87% Frequently 62% Prefer Not to Answer 6% NO 7% 3-4 Times per Year 14% 1-2 Times per Year 14% Never 1% No Other Providers 9%

Services Summary 32 Birth to Three service providers are diverse in discipline, education, and levels of specialization ( expertise ) Majority of these providers primarily treat children with hearing loss Majority of these children are seen less than weekly Most services are received in the home Family participation reduced in services outside of the home

Next Steps 33 Does provider specialization: influence outcomes in speech, language, relate to parent satisfaction and buy-in to intervention impact the amount that amplification is utilized Many more questions To what degree, if any, does site of service (and related characteristics) affect outcomes Continue this line of work into the pre-k, school-age, and audiology service provider surveys

Audiology Findings Follow-up after newborn hearing screen Hearing aid use time Quality of hearing aid fittings

Timing of diagnosis and intervention Factors influencing follow-up to newborn hearing screening for infants who are hard of hearing (Holte et al., 2012) Research questions: How do family and child-specific factors affect timely diagnosis and follow-up? How consistently are hard-of-hearing children receiving appropriate care and follow-up within the best-practice 1-3-6 timeline (JCIH, AAP, NIH)? What reasons are given by families for delays between various steps in the EHDI process? Participants: 193 children in the OCHL sample who referred on NHS

What factors affect follow-up? 18 16 p =.0445 14 p =.0013 12 p =.0123 Age (Months) 10 8 6 4 High School or less (n=34) Some College (n = 65) Bachelors (n = 50) Post Graduate (n=43) 2 0 Age of First Eval Age of Confirmation Intervention Age HA Fitted Follow Up Step

Percentage of children meeting 1-3-6 guidelines following failed NHS 100 90 80 70 Percent of Group 60 50 40 30 20 10 0 Screened by 1 month First diagnostic ABR by 3 mos HL confirmed by 3 mos Follow-Up Steps HA fit within 1 month of HL confirmation Entry into EI by 6 months

Reported reasons for delays Multiple rescreenings (up to 10) or retesting Family assured that failed screen was caused by something other than permanent hearing loss Family told by primary care physician to wait until behavioral testing was possible Family or physician did not believe child had a hearing loss due to observable responses to sound Difficulty obtaining appointment for ABR, medical clearance for hearing aids or hearing aid fitting Recurrent otitis media

Conclusions Many families accessed care following failed newborn screening within recommended 1-3-6 time frames. In a group of children who are hard-of-hearing, higher maternal educational levels were significantly associated with earlier confirmation of hearing loss and fitting of amplification. Severity of hearing loss was not. There remains confusion by some families about the possibility of hearing loss in infants and toddlers who display awareness of sound. Educational resources and training should address this specific gap in understanding.

What predicts how much children are wearing hearing aids? Predictors of hearing aid use time in children with mildsevere hearing loss (Walker et al., in press) Research questions: Which factors predict daily HA use time in children who are hard of hearing? How consistently do children wear HAs in different settings? Are parents accurate at estimating average daily hearing aid use time? Participants: 272 HH children in the OCHL sample

Methods Participants Participants n=272 Hearing aid questionnaire average # of hours child M Range used HAs per day Age at test 40.5 5-87 consistency of use, rating how (months) often the child wore HAs in 8 contexts Age HL 11.7.25-70 in the car, school, daycare, confirmed meal times, playing alone, book sharing, playground, (months) and in public Age HA fit 15.0 1.5-72 situations that were (months) challenging for consistent HA use Hearing aid Datalogging Better Ear PTA (db HL) 49.6 16.25-82.5

What factors predict daily HA use time in children who are hard of hearing? Chronological age, better-ear PTA, maternal education level, and test site had significant effects on daily HA use time. Children who wore their hearing aids for more hours tended to be older, have poorer hearing, and their mothers tended to have higher maternal education level. Children at the UNC site wore HAs one hour longer than children at the Iowa site, on average. Child s gender, age at HA fitting, or length of HA experience did NOT predict daily HA use time.

How consistently do children wear hearing aids in different settings? Car: 35% of parents of infants (0-2 yr) responded that their child always used HAs in the car, compared to 78% of parents of preschool (3-4 yr) and school-age (5-7 yr) children. Public: Most parents of older children reported that their child always used HAs in public settings; infants showed less consistency. Daycare: Infants (58% always responses) were less consistent than preschoolers and school-age children (approx. 80%).

Are parents accurate at estimating daily hearing aid use time? Parent report = 10.84 hours Data logging = 8.3 hours Average difference = 2.6 hours

Conclusions Severity of hearing loss, age, and maternal education level were significantly related to the amount of time children wore their HAs. Younger children and children with milder hearing losses wore HAs less consistently than older children and those with more severe hearing loss. Parents overestimated the amount of time their child wore their HAs, but the correlation between parents estimates and datalogging was very high. Clinicians may rely on parental self-report of HA use time as a general estimate of how much the child wears HAs. Caveat: HA datalogging and consistency ratings are preferred with parents of younger children when monitoring device use.

Hearing loss and audibility For years, we have looked at audiometric thresholds (pure tone average) as a predictor of later speech, language, academic and psychosocial outcomes We hypothesize that access to speech (via hearing aids) is more likely to predict the child s success in life. HOW do we quantify access to speech? Speech Intelligibility Index (i.e., count the dots )

Quantifying audibility: Speech Intelligibility Index Each dot represents ~1% of the information contributing to speech clarity. Number of dots that are audible predict how well one understands quiet speech from a six foot distance. The dots are unevenly distributed, with many more of them filling in the gray zone between 1000 and 3000 Hz than in the 250 to 500 Hz area.

Hearing loss and audibility 49 SII = Sum of weighted audibility of all frequency bands OCHL Advisory Board Meeting

What is the quality of hearing aid fittings for children in the real world? The characteristics of hearing aid fittings in infants and young children (McCreery, Bentler, & Roush, in revision) Research questions: How close are hearing aid fittings to targets? Speech intelligibility index (audibility) 0-1, with 1 = completely audible RMS error to target (fidelity of treatment) RMS error < 5 db = optimal HA fitting What impacts quality of HA fittings?

SII How close to the target? Target vs. Measured SII 1.0 Measured SII Target SII 0.8 0.6 0.4 0.2 0.0 0 50 100 150 200 Subject Number (n = 208)

How well are HAs fit in the real world? Optimal fitting of hearing aid (< 5dB RMS error) Filled symbols = rms error < 5 db Open symbols = rms error > 5 db n = 195 McCreery, Bentler, Roush, in revision

What impacts quality of fitting? Verification technique: Manufacturer s default settings DO NOT USE: will result in too little amplification for child. Functional gain/aided soundfield testing ONLY USE: for validating CI & bone conduction devices Speechmapping Real ear-- most accurate estimate of how child is hearing with hearing aid on the ear. Simulated real ear-- estimate of how child is hearing Measure RECD to accommodate for differences in ear canal shapes and sizes (PE tube, TM perf), which can affect thresholds. Use Average RECD when unable to measure.

Summary for audiology section 54 Timeliness of intervention: Higher levels of maternal educational levels were significantly associated with earlier confirmation of hearing loss and HA fitting. 32% of HH children met all three JCIH benchmarks screened by 1 m, confirmed by 3 m, intervention by 6 m. Characteristics of daily HA use time: Younger children and children with milder hearing losses wear HAs less consistently than older children and those with more severe hearing loss. Parents tend to overestimate daily HA use time, but the correlation between parents estimates and datalogging is very high.

Summary for audiology section 55 Characteristics of HA fittings There are a number of children who could be more optimally fit with HAs Verification techniques influence optimality of HA fittings How do these factors relate to speech and language outcomes? We see variability in the length of HA experience, amount of HA use, and amount of aided audibility (SII) these factors may directly influence outcomes or interact to influence outcomes.

Communication Outcomes Findings Relative vulnerability of outcomes Speech and language Emergent and early literacy skills Social-cognitive development Inconsistent access hypothesis Protective factors

Relative vulnerability to effects of HL HH Group NH Group 55 70 85 100 115 130 145 VOCABULARY SKILLS GRAMMAR USE SPEECH PRODUCTION PRINT KNOWLEDGE PHONOLOGICAL AWARENESS SOCIAL REASONING BELOW AVERAGE AVERAGE ABOVE AVERAGE

Language: CASL, 3 Years 59 M = - 0.59 M = - 0.59 M = - 0.73 Mean Standard Scores CASL Subtest NH (n=42) HH (n=116) Basic Concepts** 104.4 94.3 Pragmatic** 99.0 89.6 Syntax** 94.0 83.7

Language: MBCDI Upper Extension, 3 Years 60 ** ** ** NH n = 35 HH n = 90 M = - 0.53 M = - 0.52 M = - 0.73

Language: PPVT and CELF, 5 years 61 M = - 0.95 M = - 1.23 Mean Standard/Scaled Scores NH (n=45) HH (n=112) PPVT** 114.7 101.8 CELF Word Structure** 12.4 8.8

Language: PPVT and CELF, Longitudinal 62 PPVT, HH n = 33 CELF Word Structure, HH n = 34 M = - 1.30 M = - 1.39 M = - 1.75 M = - 1.53 No significant difference from ages 5 to 7 for either test (ps >.30).

Speech: GFTA 63 GFTA-2, Cross-sectional results for NH and HH groups at 3, 5, 7 years ns and Mean Standard Scores NH HH Age n M n M 3 Year** 43 99.3 116 84.7 5 Year** 44 105.3 125 91.6 7 Year** 24 103.9 70 93.7

Speech: GFTA, Longitudinal 64 GFTA n = 36 n = 33 M = - 0.94 M = - 1.24 M = - 1.43 M = - 1.20 No significant differences between 3 and 5 year scores (p =.110) or 5 and 7 year scores (p =.318).

Early Literacy: TOPEL, 4 years 66 M = -0.78 M = 0.16 Mean Standard Scores TOPEL Subtest Phonological Awareness** Print Knowledge NH (n=49) HH (n=116) 102.7 90.1 103.6 105.8

Early Literacy: TOPEL and CTOPP, 5 years 67 M = -0.24 M = -0.64 M = -0.83 TOPEL PK CTOPP PA** CTOPP PM** ns and Mean Standard Scores NH HH n M n M 45 108.4 128 105.7 41 101.5 99 94.1 41 98.6 99 89.6

Early Literacy: WRMT-R, 6 Years 68 Woodcock Reading Mastery Test - Revised Mean Standard Scores M=-0.42 M=-0.56 M=-0.34 WRMT-R Subtest NH (n=37) HH (n=110) Word Attack* 118.7 111.5 Passage Comprehension** 117.8 106.6 Word ID 121.8 114.9

Social Cognition (Theory of Mind), 5 years 70 n = 45 n = 123 NH pass rate = 84% HH pass rate = 36% Between groups X 2 : p <.001

Relative vulnerability to effects of HL HH Group NH Group 55 70 85 100 115 130 145 BELOW AVERAGE AVERAGE ABOVE AVERAGE VOCABULARY SKILLS GRAMMAR USE SPEECH PRODUCTION PRINT KNOWLEDGE PHONOLOGICAL AWARENESS SOCIAL REASONING Less vulnerable (strength) More vulnerable More vulnerable Less vulnerable (strength) More vulnerable More vulnerable

Inconsistent access hypothesis Why are children with hearing loss at risk for communication delays and why are some domains more vulnerable than others?

Inconsistent access hypothesis 73 Children with hearing loss experience inconsistent access to linguistic input, due to: Periods without amplification Delays in hearing aid fitting Inconsistent hearing aid use Limitations of hearing aids Bandwidth Audibility Interaction of HL with negative environmental acoustics: distance, noise, and reverberation

Inconsistent access hypothesis: Areas of vulnerability 74 Effect of HL on language development interacts with the degree to which language learning requires processing of subtle acoustic cues and the audibility of those cues. Morphemes, especially for verbs, have low phonetic substance (Hseih, Leonard, & Swanson, 1999) Less frequent in the input Typically sentence medial (He needs to find ) Often involve fricatives in English Complex phonetic contexts (It s, Greg s calling )

Inconsistent access hypothesis: Areas of vulnerability 75 Accessing multi-talker conversations may also be especially difficult, leading to delays in social cognitive development. Social-cognitive development may also be affected by weaknesses in syntax/language and other factors. More research is needed on the mechanisms that affect development in this domain.

76 Protective Factors What protective factors result in resilience?

Protective Factors Milder degree of hearing loss Better audibility Well-fit amplification Early hearing aid fitting Amplification worn consistently Timely and effective early interventions Focused exposure Increased quantity of linguistic input in the home More resourced homes Strong cognitive abilities

Severity of hearing loss 78 CASL Composite, 3 years GFTA, 3 years Level GFTA n CASL n NH 43 42 25-35 15 17 36-45 26 27 46-55 33 34 56-65 21 20 66-75 13 12 At 3 years, BEPTA correlated with GFTA (r = -.398**) and CASL Composite (r = -.330**).

Hearing aids: Audibility 79 Z-Score (Compared to NH Group) 3 Relationship of Audibility with Outcomes (3 years) 2 1 0-1 -2-3 -4 0.00 0.20 0.40 0.60 0.80 1.00 Better Ear SII (Audibility) GFTA r =.441** CASL r =.250** Aided audibility is a better predictor of outcomes than unaided hearing.

Hearing aids: Audibility & daily HA use 80 Amount of daily HA use At 3 years of age, amount of daily HA use was not independently predictive of outcomes. However, daily HA use interacted with audibility. Audibility affected outcomes least for children with the highest amounts of daily HA use - that is, when children s HAs don t provide them with good access to the speech spectrum, consistently wearing their HAs is especially beneficial.

81 Hearing aids: Audibility & length of HA experience Length of HA experience Length of experience with hearing aids was calculated for the 3-year-old group by subtracting age at HA fitting from chronological age. Experience with HAs was not independently predictive of communication outcomes. However, length of HA experience interacted with audibility. Audibility affected outcomes least for children with the most hearing aid experience (fit with hearing aids the earliest).

Early Intervention Services 82 Contribution of number of early intervention visits per month to CASL Scores at 3-years (regression results) 37% 40% Covariates (sex, race, maternal ed**, PTA) Number visits per month** 23% Unexplained

Linguistic input 83 Automated analyses were utilized to examine full-day recordings of the auditory environments of 28 HH 2 year olds. Children administered Mullen Scales of Early Learning (MSEL) at 2 years and the CASL at 3 years.

Linguistic input 84 MSEL T-Score 80 70 60 50 40 Receptive Expressive The number of parent-child conversational turns was significantly correlated with children s concurrent receptive and expressive language abilities (r =.661**, r =.454**), as well as their language abilities at 3 years (r =.449**). 30 20 0 20 40 60 80 100 Conversational Turn Count (per hour)

Linguistic input Conversational Turn Count 100 80 60 40 20 r = -0.52** Conversational interactions were less frequent in homes with high rates of audible television, which in turn predicted weaker language skills for HH toddlers in those homes. 0 0 5 10 15 20 Electronic Media (percent of recording)

Parent resources 86 Relationship of Maternal Education with Outcomes Z-Score (Compared to NH Group) 3 2 1 0-1 -2-3 -4 GFTA r =.236* CASL r =.360** 9 12 15 18 21 Maternal Education (years) Income also significantly correlated with GFTA (r =.198*) and CASL Composite (r =.306**).

Cognitive abilities 87 Z-Score (Compared to NH Group) 2 1 0-1 -2-3 -4 Relationship of non-verbal IQ at 4 years with language at 5 years WPPSI Block Design PPVT, r =.462** CELF Word Structure, r =.410** -4-3 -2-1 0 1 2 WPPSI Z-Score (Compared to NH Group) Similar results for WPPSI Matrix Reasoning (PPVT: r =.508**, CELF Word Structure: r =.455**)

Summary 88 Hearing loss places children at risk for delays in communication development risk is most often realized in areas that require access to structural aspects of language or multi-talker conversations. Protective factors include early and consistent use of well-fit hearing aids, appropriate early intervention services, high rates of linguistic input, and a variety of other parent and child factors.

Summary 89 Although between-group differences existed on most communication outcome measures, the HH group often performed within one standard deviation of the NH group. The question arises What does it mean to be functioning at the bottom of the average range and why do we need to focus on protective factors? Our theory: Cascading effects Need to examine school-age outcomes

Thank you 90 We d like to thank our OCHL families and service providers for their continued support and encouragement. www.ochl-study.org