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Longitudinal Study: Outcomes for Children with Hearing Loss Transcript

Longitudinal Study: Outcomes for Children with Hearing Loss

Elizabeth Walker, PhD, CCC-SLP/A

[Woman stands on a stage next to a PowerPoint slide that says, “Outcomes of Children with Hearing Loss: Results from multicenter, longitudinal study” with Elizabeth Walker’s name and credentials. Next to her credentials is an image of a family.]

Elizabeth Walker: I am an assistant professor at the University of Iowa, so just south of here. I did get my graduate degree at University of Minnesota, so I have a bit of a Minnesota connection, so it was really nice to be able to come back up here. So, my history, I am, like I said, I received my master's degree in communication disorders at the University of Minnesota Twin Cities, and I actually -- I couldn't decide if I wanted to do audiology or speech pathology, so I decided to do both. 

[A PowerPoint slide appears titled, “My History” with photos of different cities. The slide describes Walker’s history.]

So, I got my master's degree in both, and then worked for a couple years as a speech pathologist and an audiologist, and then I decided that my heart was really in doing research and teaching. So, I received my PhD in speech and hearing science in 2010 from the University of Iowa, and I'm currently an assistant professor at Iowa. 

[A PowerPoint slide titled, “Overview”, appears next to Elizabeth with several headshots of children. Next to each child is a phrase.]

So, this is just a brief overview of the talk that I'm going to give today. I'm going to give you an introduction for a longitudinal study that I've been a part of for almost the last ten years. And this is called the Outcomes of Children with Hearing Loss study, or OCHL, So, we use that acronym for it. So, I'll give you an introduction on what the study's about, who participated in the study, and then I'm going to talk about kind of a big-picture concept. And talking about what are best practice goals for children who are hard of hearing? The talk today is really focused on children with mild and moderate hearing loss. So, what are best practice goals? And I'm going to use the acronym, the acronym ACCESS to describe the research that's come out of this longitudinal project. And then I'm going to talk about some future directions, some projects we have coming up, and then after this, I'll have my Fireside chat so, you guys are welcome to come and talk to me about any ideas you guys have. So, like I said, this talk today, my talk, is really focused on children who are hard of hearing. So, not children who are deaf, but children with mild and moderate hearing loss. 

[A PowerPoint slide appears, that is titled, “Why studying children who are hard of hearing?”, with a photo of a woman smiling. Next to the photo is a quote from Julia M. Davis from 1977.]

And we really don't know a lot about this population. Julia Davis was a professor at the University of Iowa in the '70s and '80s, and then she came to Minnesota and was the Dean at the University of Minnesota. In the '90s, and she wrote a book in the 1970s called Our Forgotten Children and this book was about children with mild and moderate hearing loss, and in the book, she talks about how we just really don't know a lot about this population. Most of the research that's been done has been done on children with severe to profound hearing loss. So, children who are deaf. And these are obviously very very important studies, it's very important to know what's going on with that population, but those results may not necessarily apply to these children with mild to moderate hearing loss. A lot of whom are being educated in regular education settings, and who have parents that are using spoken language with them. So, the research that's been done with children who are deaf may not be applicable to children who are hard of hearing. And, she wrote that in 1977, but, really, even now we still don't know a whole lot about these children who are hard of hearing. 

[A PowerPoint slide titled, “New Practices New Outcomes” appears. Along with text there are several photos of babies, as well as photo of a young child sitting at a desk, frustrated, and a photo of a woman reading to a child.]

So, the focus of the Outcomes of Children with Hearing Loss Study, is that we have new practices with this population, so we wanted to see does this lead to new outcomes. So, we now have the new generation of children who are hard of hearing, who are being identified with hearing loss at birth, through newborn hearing screening, and they're being fit with hearing aids at very young ages. They're receiving family-centered early intervention practices, and we wanted to know, what are the outcomes of these kids? Because nobody had really looked at that in the United States in a large-scale study. We wanted to know, are these children at risk for delays? And we also wanted to know, what are factors that lead to success for this population? So, these children with mild and moderate hearing loss.

[A PowerPoint slide appears, titled “Previous outcomes research”. There is a rectangle and triangle on the opposite side of the slide. They are connected by a line. They each have text inside them, but they are too blurry to recognize.]

A lot of the previous research that's been done on this topic, that's looked at kids who  are hard of hearing, and research in that area, has really focused on the severity of their hearing loss. So, does having a mild hearing loss lead to better outcomes than having a more severe hearing loss? [Walker coughs] Walker: Excuse me. What about children with moderate hearing loss? It's really focused on the pure tone average of the audiogram. So, what are these kids' hearing levels? And we feel that that's not really the appropriate way to be getting at, what are the outcomes for these kids? One of the problems with looking at it that way is that there's been historical ambiguity. There's been ambiguity about how much of a risk is there, -sorry, I'm losing my voice a little [Walker coughs]. How much is there a risk for having a mild to severe hearing loss? 

[A PowerPoint slide appears, with a table that has information from several studies. Most of the title of the slide is covered by a speech bubble. The speech bubble has several lines of text, but the text is too blurred to see.]

Some studies, the studies that you see on the blue side, have indicated that any degree of hearing loss puts the child at risk for possible spoken language delays. And these studies have indicated that even children with mild hearing loss are at risk. It is studies on the yellow side, on the other side, however, have been done with children with mild to moderate hearing loss and they indicated that having a hearing loss to this degree poses no risk. These children will be able to develop language skills appropriately with their same-age hearing peers. And, so, it's really, it's been a mixed bag of research over the years. The problem with these studies, however, is that you'll see the N is how many subjects are in the studies, they've been very small samples. They haven't been able to recruit a whole lot of kids to be able to look at this. They've also had a very wide age range of children who have participated in these studies. And they tend to be more school-age children. So, the small sample sizes, the focus is more on school-age children, the focus a lot of times is on how severe is the hearing loss, and they haven't thought about malleable factors, these studies. What we can do that we have control over as an audiologist or a speech pathologist to try to improve outcomes for these kids. So, what kind of language access are they getting? What kind of intervention are they getting? That hasn't been the focus of the past research that's been done.

[Another PowerPoint slide appears, titled “Previous Outcomes Research”. Again, there is a rectangle and triangle connected by a line, and the text in each is not undecipherable.] 

So, like I said, and then another aspect of it is that a big part of the focus has been age of identification. When are these kids getting identified with hearing loss and how does that impact outcomes? 

[A PowerPoint slide appears with a bar graph. The x-axis is titled Age of Identification (Months) and the Y-axis title is too blurry and so is the text explaining what study this graph is from. There is text that is visible that says, Pure Tone Average Cognitive Quotient.]

Studies by Christie and others have found that the earlier the child is identified, the better the outcomes. If you can identify a child with hearing loss before 6 months of age, they tend to have better language outcomes. 

[A PowerPoint slide appears that says, IF AT question #1. There is text below this text, but it is too blurry to describe. Next to the text is a screenshot of a document.]

But, okay, so here, do you guys have the little scratch-off? Okay, good. So, I want you to get together with people at your table, and we're going to, -so what you're going to do, you're going to go to question number 1 and scratch off which answer you think is the correct one. And if you get the correct answer, you're going to see a little star in your box. So, do this with the people that you're sitting next to, okay? And, so, the first question is, what's a limitation of looking at age of identification or age at which they get hearing aids to predict outcomes? And A is there a wide range of ages at which they're identified with hearing aids or fit with hearing aids. B is age of identification doesn't really reflect how much auditory access they have from their hearing aids. C is this is hard -- just hard to get this information, to find out what age they were when they were identified. And then, D is, newborn hearing screening doesn't really matter. So, get with your partners. See what you think. See what you think is the correct answer. Some of these questions you may not agree with the answer, so we can talk about that more later. But for me, the correct answer was that these issues of timing, when they get their aids, when they're identified, that doesn't reflect individual differences of the child and when they're wearing their hearing aid and how much audibility they get from the hearing aids. Okay.

[A PowerPoint slide appears, titled, “OCHL outcomes model: auditory-linguistic access”. On the slide there is a diagram with different shapes with text inside them, connecting to one central one. The text is too blurry. There is visible text under that diagram says, “Factors that influence relationship between PTA and outcome”.]

So, like I said, previous research has really focused on degree of hearing loss, age at fitting. We feel like that isn't giving us a whole picture of these children with mild and moderate hearing loss. And, so, what we've proposed as part of the OCHL study is what we call the auditory linguistic access model, and here we're looking at not just at the factors as pure tone average and age of identification, but also how well fit are the hearing aids, how often are they wearing the hearing aids on a daily basis, and what kind of linguistic input are they getting from the parents. And we consider these to be malleable factors, these factors in the middle are factors that we have control over as clinicians when we're working with these children, okay? And that we can use to benefit the children.

[A PowerPoint slide appears with a map of the Midwest United States. There are different markings on different parts of the map. The text on the slide says, “The OCHL stud is a multicenter, multidisciplinary, longitudinal study focusing on outcomes of children with mild-severe hearing loss”. In the corner is a table with two columns, subjects and total.]

All right. So, like I said, I'm going to give you a little bit of quick background of the OCHL study. This is a multicenter, longitudinal study, it's been going on since 2008, and it really focuses on children with, -we say mild to severe hearing loss, but most of the children in the study had a mild or moderate hearing loss. It was multicenter, because we had children recruited from three different primary areas. The yellow push pins show children that were recruited through the University of Iowa, so, they're yellow for the Hawkeyes. I heard a boo there, that's okay. I'm also a Gopher. The red push pins show the children recruited through Boys Town National Research Hospital in Nebraska. So those were the cornhuskers, I would definitely say boo for that. And then the blue push pins show children that were recruited through University of North Carolina Chapel Hill, so these were children that were basically, -we called them the Tar Heels. We ended up recruiting 317 children who are hard of hearing for this study across 16 different states. And we also had a control group, a comparison group, of children with typical hearing, 117 children that were matched by age and socioeconomic status to our children who are hard of hearing. So, this is the largest study that's been done on this population in the United States up to this point. 

[A PowerPoint appears, titled, “Study participants: Inclusion criteria”. Under there are five text boxes.]

So, in order to participate in the study, we had pretty strict criteria for who was qualified for this study. They had to be between 6 months and 7 years of age at the time they enrolled in the project, - we're continuing to see them today so some of them now are in seventh and eighth grade. Spoken English had to be their primary language. So, we didn't include children that were learning Hmong as a second language or Hmong as their first language, or Spanish as their first language because all of our tests that we were administering were in English, and we wanted to be able to really isolate the effects of how are these children learning English. They didn't have any major secondary disability. So, we excluded children that had cognitive impairments, motor impairments, visual impairments that couldn't be corrected to within normal limits. We also excluded children with cochlear implants. We wanted to focus in this study on what the effects of hearing aids were on language outcomes. And there's been a lot of research done on cochlear implants, but that was not the population of interest in our study. So, we did not include any children in the study who had implants. And then finally, they had to have a permanent, mild to severe bilateral hearing loss. So, we also did not include children with unilateral losses, so a hearing loss in one ear.

[A PowerPoint slide appears that is titled, “Study participants”. Below the title is a table of values from a study. Under the table is a photo of a child at a doctor’s appointment, and next to that photo is a photo of a van.]

Like I said, we had 317 children who are hard of hearing, most of them had a congenital hearing loss. 76% were identified through newborn hearing screening. We had a typical hearing group that was our comparison group. And, so, these children were matched on both income and maternal education level and age. One thing I want to point out about our children who are hard of hearing and our children with typical hearing, is that their income level and maternal education level was higher than the average U.S. population. So, this was an advantaged cohort of children. And that wasn't because we tried to exclude lower-income families. Those children were just harder to recruit into the study. And, so, when we compared our kids to the U.S. census data, our families were more economically advantaged. We tested the children, -we've tested them almost every year for the past ten years. We go -- in Iowa, we actually have a white van. You see the van there. We go and test the kids in that van. We go to the families' homes and do the testing in their driveway. So, at this point, the kids know, the van's coming. There's candy in the van. There's toys. So, they all come running out and can't wait to get into the van. It creates a problem with their siblings because the siblings all want to come in the van too. So, we usually have some kids standing outside of the van looking kind of forlornly at us because they also -and then we let them in the van when we're all done and they can get candy, too. So, we have no problem with bribery. So, as I present the data from this study, I do want you to keep in the back of your mind, there are some caveats to this study.

[A PowerPoint slide titled, “Caveats for OCHL” appears. There are lines of text below the title.]

First of all, our interest in this project was what are the spoken language outcomes for these children. So, we were looking at, how they were acquiring spoken English, also keeping in mind, the socioeconomic status of the group was advantaged. Their language background was spoken English. We excluded children with additional disabilities, and then we only, - if we did have kids with cochlear implants that got their implants as the study went on, which did happen, we only included their data prior to implantation.

[A PowerPoint slide titled, “Overview”, appears with several headshots of children. Next to each child is a phrase.]

So, keep that in mind as we're talking about the data. So now I'll talk about this acronym I want to discuss today, the big picture of what kind of access are these kids getting and how does that relate to their outcomes.

[A PowerPoint slide appears, titled “Importance of access to input”. Under the title are examples of this importance.]

So, as they we about earlier this morning, it's really this idea of access to language input is critical. That's really the critical message here. And if a parent chooses to use a visual language, that is wonderful because they are getting a full access to language. If the parent chooses to use spoken English, that's important, too. The key thing is that they're getting this language input, that's essential to language development. We know that just having exposure to words, having exposure to language, is a very potent factor in language development, and having that input can be really important. And we also know that infants are very active learners, and they are constantly, - there's research that shows they can do these very complex statistical learning paradigms, where they can find patterns in the input that they're receiving and learn the rules of made-up grammars just by listening or by being exposed to input. So, our goal for these children, for children with mild to severe hearing loss, mild to profound hearing loss, is that they have rich input and good access to language. So, the problem, though, is that for some of these kids, the access can be limited, or it can be inconsistent. And in those cases, language learning can be difficult. 

[A PowerPoint slide, titled, “Barriers to access” appears, with a photo of a road barrier. Under the title are examples of barriers.]

So, there are different barriers to access. I'll talk about some of these today and how they've impacted the outcomes for the kids in our study. First of all, degree of hearing loss can be a barrier. Also, having a delay in hearing aid fitting. Like I said, those have been really the primary focus of the research up to this point. But also, just wearing the hearing aids inconsistently can also, we suspect, have an impact on outcomes. And getting variations in linguistic input can also, -just not having consistent input from a family, from parents, can also lead to delays. 

[A PowerPoint slide titled, “Best Practice Goals’ appears, with a list of examples of best practice goals.]

So, here are the best practice goals that I want to talk about. And I'm going to talk about how our research relates to each of these goals. So, the first one I'll talk about is, A, for access. All families, -we want to see, are they all receiving timely follow-up?

[PowerPoint slide appears that has text that says, “ACCESS”, “All families receiving timely follow-up”, “How are we doing?”, “Practice implications”, and “Early Hearing Detection and Intervention Program”.

So, one of the questions for this study, on children who are hard of hearing was, how are we doing in terms of having them receive timely follow-up? And what are the practice implications?

[PowerPoint slide titled, “EHDI “1-3-6” benchmarks”. Under the title, there is text that says, “ICIH and AAP (2007)”. Also, on the slide there is a diagram of rectangles connected to each other by arrows”.]

So, some of you may be familiar with the Early Hearing Detection and Intervention benchmarks. We call these the 1, 3, 6 benchmarks, and this has been proposed by the joint committee on infant hearing in the American Association of Pediatricians. And here they are proposing. We want to see children have their hearing screened by 1 month of age. Have their hearing loss confirmed by 3 months of age, and then start receiving early intervention by 6 months of age. We want the early intervention to be family-centered and preferably in the home. Also, within there, within this 1, 3, 6 benchmarks, JCIH has also proposed that hearing, -we want to see the hearing aid fitting occur one month after the confirmation of hearing loss.

[A PowerPoint slide appears, titled, “What factors influence follow-up to newborn hearing screens (Holte et al., 2012)?”. Under the title are two photos of babies and information from the Holte study.]

So, one of the questions we had for our research study is, okay, are kids meeting these benchmarks?  Are we seeing that kids are having this, -meeting these 1-3-6 goals, or are there delays in the process? And if there are delays in the process, what are the factors that are influencing timely follow-up or delays in the process? So, this study, -this was a paper that we published in 2012. We looked at 193 children who had participated in the study, our OCHL study, and these were all children who referred on the newborn hearing screening. So, we wanted to see, how quickly are they getting follow-up after they've been identified by the newborn hearing screen, and then what family and child-specific factors affect diagnosis and follow-up.

[A PowerPoint slide with a bar graph appears. At the top of the PowerPoint, there is text that says, “Timing of services—what happens after NHS?”. There is also text at the bottom of the slide that says, “Only 32% of 193 children who referred UNHS met all benchmarks on time”.]

So, what we found was, now, not surprisingly, 100% of the children, of this sample, were screened by 1 month of age, because these were all children that we knew had not passed the newborn hearing screen. After that point, we see the green bar show the percentage of children that met the 1-3-6 benchmarks, and you'll see that most of them were having their confirmation by 3 months of age, so 83%, - sorry, 64%, so the majority of them met that goal. 75% were entered into early intervention by 6 months of age. But we also looked to see how many children met all three of those goals, the 1-3-6, and we found that only 32% who referred on the newborn hearing screen met all of the benchmarks on time. So, for the majority of children, there was some delay in the process following newborn hearing screen. 

[A PowerPoint slide appears with a bar graph, and is titled, “What factors affect follow-up?”.]

We also looked to see what factors affected follow-up. When this research has been done in the past, before we had newborn hearing screenings, the big factor that affected follow-up, or delays in follow-up, was the degree of hearing loss. Children with milder losses tended to get identified later, started intervention later, had the hearing loss confirmed later. So, now we've got these children that are have been identified through newborn hearing screening, -and we did not find that degree of hearing loss affected the length of when they received these services. The only factor that made a difference was maternal education level. And, so, you can see here, the black bars show mothers that had a high school education or less. The white bars and the light gray bars show mothers that had a college degree or better. And along, -I can't point very well, but along, -we have age at first evaluation, age at confirmation, age at intervention and age at hearing aid fitting. And you'll see that the black bars, those kids tended to have delays in this process, okay? So, those kids tended to be delayed in these 1-3-6 steps.

[A PowerPoint slide titled, “Practice Implications” with information appears.]

So, what are the implications here for this research? Well, we want to see, do all families actually receive timely follow-up? And we found that there were delays in the process. So, some of the practice implications, -one of the things that we found were children were being rescreened over and over and over again. They failed the newborn hearing screen. They went back to the hospital. They had another screen. They went back to the hospital. They had another screen. And they didn't go on and get that diagnostic testing. And, so, that was one practice implication that we found, that we shouldn't be   rescreening the kids over and over and over again. If they've failed the -- if they've referred on the newborn hearing screening twice, they should go on and get a diagnostic hearing test. We also need to, and this is difficult, especially in rural states, like where I come from in Iowa, trying to have more access to specialized providers, particularly pediatric audiologists and knowledgeable physicians. We had some families that said, -again, these were mild to moderate kids, so these kids had residual hearing, and we had some kids, -their physician told them, oh, you don't need,- they failed the newborn hearing screen, but that's okay, look, when I stand behind them and snap my finger. They turn their head, and, so, they can hear me just fine. You don't need to go and get this extra hearing test. Or you can wait until they're older, they'll be just fine. And also, the big key here was, we found that these families, these lower socioeconomic families, seem to be at risk for delays in the process. And, so, we need to find more ways to support these families that are at risk. Trying to, - one of the big issues is transportation, just trying to get to the appointments for the diagnostic hearing testing, for the hearing aid fittings. So, trying to get families to be able to access those services. Okay. So, we also -- you know what? I'm pretty sure I'm going to run out of time, so I'm going to skip ahead here a little. All right. 

[Walker skips several slides.]

[Walker stops on a PowerPoint slide that says has a diagram from a study. Next to the diagram is a quote from the study.]

So, big picture, the slides I just skipped ahead on were looking at children who were later identified with hearing loss. 

[Walker changes the slide again to one that is titled, “Practice implications: Late Identification” with different bullets. One of the bullets is bolded and says, “Enrollment into early intervention has the potential to reduce delays”.]

And what we found with those kids were children with mild hearing loss, if they're late identified, they tend to be really delayed in the process of getting services. Also, we had children who passed the newborn hearing screening ,and then referred for early intervention services because they had a language delay and then never had their hearing tested.

[Power Point slide appears, titled, “Big picture findings: Age at service delivery”. There are three text blocks with statements inside each of them.]

And, so, they were getting services that probably weren't appropriate for what they needed. So, kind of big-picture findings for when we're looking at whether or not these kids are getting services is, children of less-educated mothers are at risk for having later diagnosis. We find later-identified children, particularly mild -- children with mild hearing loss, are getting services at later ages, and early intervention can really help these families. So, this can really help reduce the delays from having the hearing loss identified and having the hearing aids fit. Okay. 

[A PowerPoint slide appears titled, “Carefully fit and consistently worn HAs”. Under the title, there is text that can’t be deciphered. In the corner there is the word access in capitalized letters.]

All right. So, my next part I'm going to talk about are the two Cs in the ACCESS acronym, and this is carefully fit and consistently worn hearing aids. So, again, we wanted to know how are we doing here and what are practice implications.

[A PowerPoint slide appears, titled with Walker’s study hypothesis. Under the hypothesis, there is a photo of a graph and a photo of a baby. In the photo there are question marks on each side of the baby’s face.]

So, we hypothesized that having access to language is going to predict success for these children that are hard of hearing. That seems like a pretty, - I think that's a very safe hypothesis to make, but, like I said earlier, all the previous studies have just looked at the kids' hearing levels and looked at their audiometric thresholds as a predictor of success. 

[A PowerPoint slide appears, titled, “What does PTA not tell us?”. The PowerPoint slide has pictures of two diagrams. Next to one diagram is a statement that says, “How child will perceive speech will hearing aids (aided audibility)”. The other diagram has a statement next to it that says, “How different configurations may impact speech perception”.]

And we haven't really found anything. We haven't found strong correlations. So, this has led to a really murky message of, should we be working with these kids with mild to moderate hearing loss? What are the appropriate practices for these kids? The problem with that is, pure tone average is not a very good measure. It doesn't really give us a full picture of how much access these children have to speech sounds. And the reason for that is, pure tone average is just an average of how they're hearing at different pitches. So, at 500 hertz, 1,000 hertz, 2,000 hertz, 4,000 hertz. So how they're doing in kind of low and mid and high pitches. And, so, that doesn't tell us anything about how different configurations of hearing loss can impact access to speech. So, we might have a child that has a flat hearing loss, that's a pure tone average of 40 decibels, and they don't have access to anything in the speech banana that's in that red region, so they don't have access to some vowel sounds, they don't have access to some consonants. We also could have a child with a sloping hearing loss that's still a 40-decibel pure tone average. They have access to vowel sounds but they don't have access to high-frequency consonant sounds, high-pitch sounds. And then you can have a child, again, with the same pure tone average, and these children with this rising configuration don't have access to vowel sounds but they do have access to high-frequency information. The high-pitch information, for learning spoken English, is very important. Because that is how we mark different tenses, different plurals, in spoken English. So, for example, plural sounds, cats. That's a high-frequency sound, okay? So, if they don't have access to that information, it's harder to learn those plurals. Past tense, he walked to the store, again. That's high-frequency information. And if they don't have access to that information, it's harder to learn that past tense marker. The other problem with just looking at their PTA, their pure tone average, is this is looking at their unaided hearing. And, so, it's not telling us, -again, these are mild to moderate kids, they've been fit with hearing aids, and, so, looking at their pure tone average doesn't tell us what they're doing with their hearing aids. So, how are they able to access sound with hearing aids on?

[A PowerPoint slide appears, titled, “Carefully fit hearing aids”. Under the title is text and two photos. One photo is a baby and the other is a target with darts on it.]

So, one of the things we want to think about is, how carefully fit are these children's hearing aids? There are different ways that audiologists can fit hearing aids on children.  We can put them in a sound booth and test them with their hearing aids on. We can also do what are called real ear measures, where we actually look to see how much sound is being provided by the hearing aids in the child's ears with conversational speech level. And, so, really best practice is to try to use these real ear measures, we're actually measuring what the hearing aid is providing. We want to be able to provide good audibility for children and we can measure this on a scale that we call the speech intelligibility index. So, this is measured on a scale of 0, - sorry, - oops, I can't go back, - 0 to 100. Sorry, I can go back. With 0 being a score that's not audible at all to the listener, and 100 being a score that's fully audible, okay? And, we call this the speech intelligibility index. 

[A PowerPoint slide appears, titled, “How do we quantify audibility?....Speech Intelligibility Index (SII)”. The PowerPoint also has a diagram of dots.]

So, the way that we can quantify how much audibility, how much access they have to the speech spectrum, is through this speech intelligibility index measure. And we do what's called the count the dots method. So, we have the speech banana on there, and the thing to notice with this SII count the dots audiogram is you'll see some of the dots are more tightly clustered together than some of the other dots and that's because some pitches give more information than others to the intelligibility of speech. So, you're getting a little audiology lesson here. And, really, it's that 2,000 to 4,000 hertz range for English that's really important, and you'll see that's where all those dots are really tightly clustered together. So, anything above the line, the dots are inaudible.  Anything below the line, the individual can hear that information and, so, we can count the dots up, and find out what their speech intelligibility index is. Okay. So, we have a computer that can actually do this for us. So, I don't have to torture my grad students and make them go through and count all those dots up. 

[A PowerPoint slide appears, titled, “SPL-o-gram SII Snapshot”. Below the title is a diagram with several different rectangle and they are each different color.]

And, so, what it does, then, is divides up the speech banana, the long-term average speech spectrum, into these different bands. And the computer will then calculate how much information are they getting from their hearing aids in each of these bands, and then it multiplies it by a function that says, this is the pitch that's really important for being able to understand spoken English. And from there we can get a score that tells us their aided speech intelligibility index, so how much access do they have with their hearing aids on, and then also, -oops, you can't see it on the bottom here because I didn't put an arrow, but it also gives us their unaided speech intelligibility index. We feel this is a better way of capturing how much access these kids have to hearing because it takes into account the configuration of their losses, what frequency regions, which pitch regions are important for understanding English, and then how well fit the hearing aids are. 

[PowerPoint slide appears with a question and 4 options for an answer. Next to the questions and answers is a grid of blocks. Above that it says, “IF AT question #2”.]

So, you know [ahhhh], okay, we'll go ahead and do this one. I'm a little worried about time, but we'll do this one. Okay, so here's your second question. How much aided audibility is necessary to support speech and language development? So, A would be 100, because children with typical hearing are going to have an SII of 1 or 100 because they have full access to the speech spectrum. Do we want all these kids to have an SII of 1, .8, .5, or D, we don't know? we can't identify a single factor because it's much more complicated than that. So, get with your partners. Scratch off your cards. 

[The video cuts for a second.]

I'm going to have some water. Good job. Okay. So, if, you scratch your card off, D is the answer. We don't know, because it's not that simple. And we don't want to give every child an SII of 1 because that's not going to be appropriate for their, - for different children's degree of hearing loss. And it's just going to give them a distorted signal.

[A PowerPoint slide, titled, “Confidence intervals for SII when hearing aids are fit appropriately”. Under the title is another graph.]

We do have data that shows where hearing aids should be fit appropriately. So, children with a more severe hearing loss are going to have a lower SII just because of how their hearing -- because that's the severity of their hearing loss. But there are these confidence ranges, -confidence intervals, that tell us whether or not a hearing aid is fit appropriately. And, so, the stars show children who are fit appropriately based on their degree of hearing loss. The black line shows the average range, the average value for where their hearing aid should be fit based on their pure tone average. So, we've got pure tone average on the X axis, and SII speech intelligibility index on the Y axis. The dash line shows the 95% confidence intervals. So, that's the average range that we would expect children to be in that have these mild or moderate hearing losses. So, for example, it's a wide range, since there are these confidence intervals. So, for a child with a pure tone average of 50 decibels, the SII could range anywhere between 55 and ,90 and it would still be within the average range, within an appropriate range. 

[PowerPoint slide appears, with the question, “Can we assume children are fit to target?”. There is a bar graph on the PowerPoint. Under the graph is the conclusion from the graph.]

So, one of the questions we had as part of this study was, can we assume that all children are being fit appropriately with their hearing aids? All right, we have these diagnostic, these prescriptive targets, that computers can tell us, yes, based on this kid's hearing loss and the size of their ears, this is where the hearing aid should be fit. So, we can calculate what their target speech intelligibility index should be. And what we found was, -so the gray lines show the target speech intelligibility index. The black lines show the measured speech intelligibility index, so how these kids' hearing aids were actually fit. And what we found were that some kids were substantially underfit. You don't see too many of the black lines going over the gray lines because we didn't have a lot of kids who were overfit, who were receiving more amplification than they needed. But we had a substantial number of children who were underfit. And, so, what we found here is that it really matters what strategies the audiologist is using to be able to predict where the hearing aid should be fit. The audiologists that are putting their kids in a test booth and testing them with the hearing aids on, those were the kids that weren't getting appropriate amplification. The audiologists that were using the real ear measures, where they actually put a little microphone in your ear and test how loud the sounds are, those were the children that had the appropriately fit hearing aids.

[A PowerPoint slide appears that says, “Are HAs fit appropriately? Consistent bullseyes?”. Under the question are bullet points. Next to the bullet points is a graph with darts on it.]

So, what we found, we looked to see how many of these kids had appropriately fit hearing aids for 288 children in our study. And, again, we wanted to see bull's eye would be within that blue range. Those would be appropriately fit hearing aids. And what we found was that 35% of the children in our study had aided audibility, their speech intelligibility index were below the average range. So, we had -- so we had about a third of the kids who weren't appropriately fit. And those would be the kids in the pink range. All right. So, another question. You know what? Let's skip this because I'm getting a little nervous on time. We're going to skip number 3. So next question coming up, remember, it's number 4.

[A PowerPoint slide appears, titled, “Does it matter if hearing aids are optimally fit?”. There is also a diagram with several blue shapes with text connecting to a center green oval. The text is too blurry to decipher.]

All right. So, the question is, though, does it matter? Does it matter if these kids have appropriately fit hearing aids, If the goal is that they're learning spoken language. So, we want to look at these kids' aided audibility, and see if it had an impact on their language outcomes.

[A PowerPoint slide appears, titled, “Aided Audibility Contributes to Language Growth”. There is a line graph below the title and a large text block over the graph with the conclusion from the graph.]

So, what we have here, this is what's called growth curve analysis. And, so, a typically developing child is going to have a standard score of about 100, because that's average performance when they're 2 years of age, and then the line should just stay flat. Because they're making 12-month gain in 12-months' time, and, so, at 3 years of age, their standard score is still going to be 100. At 4 years of age, standard score is still be 100, So, a line in a growth curve analysis, we expect to be flat, if it's a typically developing child who's acquiring language in an appropriate manner. Oopsie. What is that?

[Elizabeth looks at her laptop confused.]

Don't know what that was. Okay. If you see lines that are going up, so, lines that have an upward trajectory, that means that children are making more gains than we would expect in 12-months' time, okay? So, they're actually catching up to their typical hearing peers. If you see lines that are sloping down, that means that the children are falling further behind, so they're making less progress than we would expect over time and getting further away from typical language development. And, so, what we found was, we looked at the aided audibility of these kids, so, their speech intelligibility index, and what we find is the purple triangles are the children that had the best audibility from their hearing aids. So, these were the hearing aids that were fit appropriately for these kids' hearing losses. After we controlled for whether they had a mild hearing loss or a moderate hearing loss, and you'll see that line, that trajectory it's doing this upward pattern. So, they're making more progress than we would expect over time. The red dots show the children who were under-amplified. So, these were the children that were getting the least amount of benefit from their hearing aids and they're showing this declining trajectory, so they're falling further behind as time goes on. So, between 2 and 6 years of age. Okay, so that's the upward line and then you see down here, these are the kids in the lower trajectory, the lower quarterly. And, so, we find that this benefit holds for children with mild, moderate, and moderately severe hearing loss. So, we find, and then, so, we can conclude from that, the children that have the appropriately fit hearing aids are showing steeper growth in their spoken language skills. Another question we have, -so, we looked at how well fit the hearing aids are. We also looked to see how consistently they are wearing their hearing aids. 

[A PowerPoint slide appears, with a question and several options. At the top of the slide it says, “IF AT question #4”. Next to the questions and answers is a grid of blocks.

And, so, here I have a question. We'll do this question, so, remember, don't scratch off number 3, because you'll get the wrong answer. Do number 4. So, what are the following reasons that are not predictors of hearing aid use in children? So, which of the following is not a predictor of how often a child is wearing their hearing aids? So, get with your partner, scratch off your card. And the answer is, A, maternal education level, B is degree of hearing loss, C is gender of the child, and D is age of the child.

[The video shifts.]

So, I heard some clapping. So, I think some people got it. So, the correct answer is gender. We did not find that gender was a predictor of how often kids wear their hearing aids. We found maternal education level was.  So, moms that had less education, those children tended to wear their hearing is less often. And we measured this by, in two ways, we asked the parents to estimate on average how often they wear their hearing aids, and then we also did something called data logging, where we can actually take the hearing aids and plug them into a computer and it will tell us how often, on average, the hearing aids are - the battery is turned on. So, we used those measures and we found maternal education level was a factor. Degree of hearing loss was a factor. So, children with milder hearing loss tended to wear their hearing aids less often than children with more severe hearing loss. And then also age was a factor. So, children who were younger tended to wear their hearing aids less often than children who were older.

[A PowerPoint slide appears, titled, “What we know about HA use”. There is a graph on the slide, and next to the slide has a list titled, “At-risk for low use” with three bullets in the list.]

And this graph shows this, this shows our data logging information where we're able to hook the hearing aids up to the computer, and we found that children who were at risk for low hearing aid use were younger, had a milder hearing loss, and had a lower socioeconomic status.

[A PowerPoint slide appears if a question and several options for an answer. At the top of the slide is titled, “IF AT question #5”. Next to the question and options is a grid full of boxes.]

So, next question. So, this is question number 5 on your card. What's the biggest challenge that parents report in getting kids to wear their hearing aids? So, we asked the parents that question. So, what do you guys think? Do you think it's changes in their routine, so going from like home to school, or going from home to the grocery store? Is it loud events? Is it equipment issues that the hearing aids just keep breaking down all the time? Or is it the child's state? So, by child state, I mean things by, are they, -their temperament. Are they ill? Are they just crabby that day and don't want to wear it? So, which of those things do you think is the biggest, - the number one thing parents told us? I keep watching this table here. They're doing really good with their cards because I keep seeing them nod. So, -oh, maybe not. Okay. So, the answer was, if you didn't get it the first time, keep scratching your card off, the answer the parents told us was child state most of the time. Particularly if the child was sick or just was having cranky that day. They said it was hard to get the hearing aids on. They very rarely ever reported that loud events bothered the kids because the hearing aids are programmed that if there is a loud event, they shouldn't amplify that sound, like fireworks going off. They also said the hearing aids didn't break very often either.  Okay.

[A PowerPoint slide appears, titled, “Does it matter if hearing aids are worn consistently?”. Below the title is a diagram of different shapes connected to each other by arrows. Each shape has text in it.]

So, again, our question is, does it matter? Does it matter if hearing aids are worn consistently for this population? And this question really had never been looked at before in children with mild or moderate hearing loss, and there's even some question, should we even do anything for these kids? Should these kids even have hearing aids? Should we not be fitting them with hearing aids?

[A PowerPoint slide appears with a line graph. Next to the graph is the title, “Consistent HA Use Benefits Growth”. On top of the graph is a text box that describes a conclusion from the graph.]

And, so, we looked at that question, and we looked at the kids who had worn their hearing aids for more than ten hours per day across the visits of the study, and then the kids who had worn their hearing aids less than ten hours per day, and, again, you see, this is that growth curve analysis. At age 2, we don't see much of a difference.  So, that's what parents report to us, too. Well, my child has a mild hearing loss, I really don't see them responding very much with or without the hearing aids on. But if we follow them over time, we see, again, these different trajectories in their language development. And the children who are wearing the hearing aids more than ten hours per day show the steep language trajectory. The children who are wearing their hearing aids less than ten hours per day are showing a declining pattern. And, so, we conclude from those data, from our growth curve analyses, that children who wear hearing aids more than ten hours per day are showing steeper growth in their language skills than the children who are wearing their hearing aids less than ten hours per day.

[A PowerPoint slide appears, titled, “Benefits of Consistent Hearing Aid Use Extends to Children with Mild Losses”. Under the title is a graph.]

The group I'm really the most interested in are these children with mild hearing loss because they actually make up about 40% of children with hearing loss, and this is the group where it's really ambiguous what kind, -should we even be providing any, intervention for these kids. And, so, we looked at this for our kids that just had a mild hearing loss, to see, do they get benefits from consistent hearing aid use? And we had children who had not been fit with hearing aids at all or had hearing aids and never wore them, and that's shown in the blue box, and then we had children who were with a mild hearing loss who were full time hearing aid users. So, they were wearing their hearing aids more than ten hours per day. And what we found was significant differences between the two groups in both vocabulary, which is shown on your left, and then also in their grammar skills, which is shown on the right. And one thing I want to point out, the hatched regions on these figures show the average range for the standardized test. So that's the normative range of these standardized tests. And you'll see that the kids with full, -that had mild hearing loss, who did not wear hearing aids, are still well within the average range, okay? That's an important point to make but, at the same time, look at the kids with full time language, who were full time hearing aid wearers. Their standard scores are actually one standard deviation above average and that's where our typical hearing comparison group also comes in at. They're actually, -again, it's an advantaged cohort, so the test norms for the Peabody, which is the vocabulary test we give them, don't really apply because of the economic advantages these kids have had. So, the children who were full-time hearing aid wearers look a lot more like our typical hearing aid group. So, the lines here just show, there was about a one standard deviation difference in vocabulary size between the non-hearing aid users, and the full-time hearing aid users, and about a two and a half standard deviation difference in grammar between the nonusers and the full-time users. 

[PowerPoint slide appears, titled, “Practice Implications” with information on it.]

Okay, so, what are the practice implications? Again, the message here is carefully fit and consistently worn hearing aids. We want to make sure that our children who their parents who are seeking these services, that want to have their kids fit with hearing aids, that we have good pediatric practices for these kids. We want to make sure that the hearing aids are being fit appropriately, according to best practice techniques, and then we also want to, -for these families that are encountering challenges with hearing aid use, we want to find ways to support those families. And I'm a parent, I've got three kids, I can't even get my 6-year-old to take a shower most of the time. So, I know how hard this is for families to get your child to cooperate with you because they have a mind of their own. But making this aware to the families and encouraging them is really, we found, has been valuable. And then understanding each family is different. Each family has their own unique needs and being able to try to address that with the families is really important.

[A PowerPoint slide appears with a question and several options for an answer. The slide is titled, “IF AT question #6”. Next to the question and options is a grid of rectangles.]

Okay. So, the last question you have on your card. I'm pretty sure this was the last one. What are strategies that audiologists can use to, -or any service provider, to help promote consistent hearing aid use? So, A is, try to discuss the challenges and the successes the families have had in identifying barriers to getting the child to wear the hearing aids. B would be, use this data logging tool. So, we have this data logging and use that, and say to the parent, no, you're not telling the truth. So, you can probably guess that's probably not the right answer. C is, use examples. Tell parents about children who have achieved consistent hearing aid use and use that to motivate families that have experienced challenges. Be like, hey, look at that kid over there is doing really good. Or, D, practice taking the hearing aids in and out. So, again, this is the last one, so, get with your table and think about which one you think is the correct answer. And there may be some other correct answer that we didn't put on this card.

[Video shifts slightly.]

So, I'm going to keep going because I've got about 15 minutes left here. So, for me, the appropriate answer, and, again, this is subjective, but identify, -realizing that each family is unique and being able to talk about, okay, what's really worked for this family, what is a challenge for this family, and recognizing it's going to be different for every family. That's a good way to identify what are barriers to hearing aid use. I don't think that saying, hey, we've got this data logging thing where we can monitor is probably not the best tool. So, and also saying, using examples of other children, or just practicing taking hearing aids on and off, probably isn't the most effective way to address this. Okay.

[A PowerPoint slide appears and has the text “Exposure to input is optimized”.]

So, we're moving along in our acronym. The E stands for, making sure that exposure to language input is optimized. So, here, we're not talking about the hearing needs, we're talking about what kind of language input is the parent giving the child. And, so, we want to see, how are we doing with this and what are practice implications.

[A PowerPoint slide appears, titled, “Acknowledgement”. Under the title is a headshot of a smiling woman.]

I want to acknowledge, -see if Sophie's picture shows up, for this research, Sophie Ambrose, who's a researcher at Boys Town National Research Hospital, has really been the researcher on our team that has looked at the impact of parent language input and, so, I want to make sure I acknowledge her, because this is really a lot of her data that she's shared with me. Okay.

[PowerPoint slide titled, “High rates of linguistic input (parent talk) especially important for children with hearing loss”. On the slide there is a photo of man smiling and holding a child. Next to the photo there is text that says, “Difficult to conduct this research”.]

So, we know, just from research on children with typical hearing, that having high rates of linguistic input, having the parent communicate with the child a lot, is really important. We also know that it's important for children that have hearing loss. One of the limitations is, this is hard research to do. It's hard to go to really effectively do this, you have to go into the family's home and record them for a number of hours and try to collect these data and, so, and then have some poor student go in and have to transcribe everything. So, a lot of this research hasn't been done very often, just because of the difficulties in conducting it. 

[A PowerPoint slide appears with text that says, “Art Gallery was conducted at 18-month visit”. Under the title are six different images.]

What we did to try to get a measure of the parents' language input to the child was do a task called the art gallery. So, what we did was we set up pictures around the room, when we saw the kids at their 18-month-old visit, and then when we saw them again when they were 3 years old. And the parents went around, and they showed the pictures to the child, each picture. and they talked to the child about what their favorite picture was, what was in the picture, and then what was their least favorite picture. And this only took about five minutes, but it gave us a lot of information for how the parent communicates with their child.

[A PowerPoint slide appears that says, “And the 3 year old visit…”. Under the text there are five different images.]

So, we did it again at the 3-year-old visit. This just shows, -I'm going to kind of move along here, just to make sure I get done on time.

[A PowerPoint slide appears but is too blurry to describe in full. There is text and an image with text boxes.]

So, the goal of this task was to try to elicit parent/child interaction. So, it's not the examiner working with the child, it's actually the parent doing this activity with the child.

[A PowerPoint slide appears, titled, “Is the language exposure rich?. The slide also has an image of a pond. There is text surrounding the image.]

Okay. So, what we wanted to find out was, how rich is the language exposure that these kids are receiving? And we're doing this with our hard-of-hearing children in the study, we were also doing it with our children with typical hearing. And, so, we did this task. Here's an example of what we considered. We went through, -after we collected all the data, we transcribed it, we wrote out, typed out what all the parents were saying, and then we coded it by, if we thought it was a high-level utterance. So, high level would be, are they following the child's lead in the conversation, are they asking them questions that aren't really about what's happening in the moment, but what's happening outside of the moment, are they using abstract terms with the child, like think, believe, know, dream. So, using language like that, in other research they've found that predicts language growth for children. And, so, we were looking at that, we coded the utterances, were they high level. So, here's an example taken from one of our samples, the mom says, what are they doing, they're looking at this picture of Winnie the Pooh, and the child says, oh, they're fishing. And the mom says, have you ever been fishing? And, so, what this is, we call this a higher-level utterance. Because they're taking it outside of the context of here and now and making the child kind of think, have you been in this situation before? And, so, the child says, yeah. And the mom says, oh, when did you go fishing? The child says, before I was born.


And what's nice about that is, the mom just rolls with it. She says, oh, and did the place look like this? And, so, she doesn't correct the child. She follows his lead and lets the conversation go where the child's taking it. So those are examples of high-level utterances. We also coded for what we call low-level utterances. So, these were questions we felt like were test questions or the parents trying to quiz the child or the parents giving the child lots of directives. So, this would be like sit down. Come over here. Look at this. What color is this? Say, say, say giraffe. So, they're really not following the child's lead. They're kind of approaching the situation with, okay, I'm going to direct my child on what to do on this task.

[A PowerPoint slide appears, “How Rich is the input?”. There is a box plot on the slide and there is information to the right of the box plot.]

So, what we found was, the children who were hard of hearing were exposed to fewer higher-level utterances with the parents. and the parents also tended to use more directive utterance, compared to our children with typical hearing. They also tended to use less complex sentences with the hard-of-hearing children, and they also used fewer different words. So, the language, the language input that they were receiving was just not as rich as what the typical hearing children were receiving. And, so, you can see that the purple boxes are the children with typical hearing, and the blue boxes are the children with hard of hearing, and you see that there were more high-level utterances for the typical hearing children and more directive utterances for the hard-of-hearing children. So, the question is, does that matter? Does this matter that they're getting this more directive talk from their parents? And the other thing I should point out, is these are box plots, and, so, it shows how much variability we get and, so, for the hard-of-hearing kids, there was a lot of variability. There were a lot of parents that were using this really rich child-centered language input with their child. 

[PowerPoint slide appears titled, “Does quantity and quality of parent talk at 18 months influence language outcomes at 3 years?”. The slide has a line graph and an image of a scale.]

Okay. So, does it matter? Does the quality and quantity of the language input that these kids are getting at 18 months of age influence their language outcomes at 3 years of age? And, so, what we found was, the quality really did make a difference. Especially how directive the parents were. And, so, what we have here is, the directedness at the 18-month visit. So, on the X axis, -so, as you go up, that means the parent was more directive. They were doing more things like sit down, stop that, come here. I should also add, this task is boring, and the parents kind of, -they get to the end, end of the five minutes, -oh, my gosh, that was torture. Because you're showing an 18-month-old artwork, and they're not super interested in it. So, some of the parents were really directive because they had to do a lot of, come here, come here, stop running out of the room. So, yeah, so along the X axis here, those would be parents who were more directive. And then along here, these are, -the Y axis shows their language scores at age 3. And, so, what we find is the parents that are more directive had children with lower language scores, and this is after controlling for degree of hearing loss and maternal education level. So, you can see here, the parents that were more directive had children with lower language scores than the parents who were less directive, okay? The parents who were less directive had children with higher language scores, 18 months later. 

[A PowerPoint slide appears, titled, “Big picture: quality and quantity of language input matter”. There is a photo of a woman and child laying on their stomachs smiling with a book. There are bullets of information next to the photo.]

And, so, the quality and the quantity of the language input that these kids are receiving does really make a difference.  Okay. So, big picture here, quality and quantity of language input in whatever mode of communication the parent, -the child is receiving really makes a difference. We found that parents of children who are hard of hearing tended to be more directive, but I also want to point out, this is possibly a bidirectional relationship. So, parents who had children with lower language skills tended to be more directive because the children weren't participating in the communication context as much. So, there is bidirectional relationship, Where the parents are being influenced by what the child is doing. We also found that using more directive communication at 18 months is correlated with lower language scores at 3 years of age. And, so, this is another area where we can really try to provide support for families to make sure we're providing optimal language learning environments for these children. All right. 

[A PowerPoint slide, titled, “Practice implications” appears. There are several bullets under the title, and under the bullets, is a photo of a woman and child smiling as they lay on their stomachs with a book.]

Okay. So, practice implications for having exposure to input be optimized. We want to make sure we're trying to increase the number of conversational turns these kids have. Another study that we did that I didn't present the data on was a project called the Lena Project, where the child actually did go around and wear a little device once a month for 12 months and we recorded the conversations that were taking place in the home. And, so, it's this little iPod device that they can wear, and it can record parent/child interactions and we found that parents that used more conversational turns with their child, those kids tended to have better language outcomes down the road. We also want to promote the parents' understanding of what conversational interactions are like, and trying to support using less directive, more responsive approach to communication interactions. Another thing that we looked at, again, I didn't have time to talk about it, but we also looked at how often the TV was on, and how much there was background noise. And we found that that played a role, too. The families that tended to have TV on as a source of background noise, -we can record that with that Lena device, those families tended to have less conversational turns. And then the conversational turns influence the language skills later on down the road. And I think what this is really all getting at is, we talk about least restrictive environments on individualized education plans, but that really isn't the right acronym. We want to promote a language-rich environment.

[A PowerPoint slide appears with text that says, “Set the bar high & Super-size services!”.]

All right. So, then the last part I'm going to talk about is making sure we set the bar high for these kids and super-size services.

[A PowerPoint slide appears, titled, “Super services: Family participation”. On the slide, there is two different pie graphs.]

So, one thing that we've looked at is, how much are these families participating in the birth to 3 services? So, we had a lot of these children who were enrolled in early intervention and, ideally, we want those services. We want the parents involved. We want those services to be taking place in the home. And, so, we ask the families and their service providers, how often are the services in the home versus outside of the home setting? 86% of the families were receiving early intervention in the home and then we had 14% that were outside of the home setting. And some of the situations that were outside the home, might have been at day care, sometimes at center-based programs for children with hearing loss, early intervention centers, sometimes at someone's office, or sometimes in the hospital. So, they were receiving private services in the hospital.

[A PowerPoint slide appears, titled, “Super Services: Family participation”. There are two bar graphs. One labeled “Home” and one labeled “Outside of Home”.]

Okay. We also looked to see, -then, we divided up the families that were getting services in the home versus the families getting the services outside of the home. If the families were getting services in the home, 95% of those families were involved most of the time. We asked their service providers to indicate how often the families were involved in the early intervention services. And the vast majority of the time, if the services were in the home, the parents were involved. If the services were outside of the home in those situations I talked about on the last slide, most of the time the parents were not involved. So, if they were at day care, at some treatment center, at some early childhood center, the parents were not participating in the services 71% of the time. And, so, this really gets at how we provide these services.  For these birth to 3 services, our goal is to try to provide them in the home. If they're not being provided in the home, though, we need to find ways to try to incorporate the families and make sure, because, really, the purpose of birth to 3 is you're working with the parents and the child, not just the child. Okay. I'm going to skip over this stuff.

[Walker skips a couple slides.]

[Slide Walker stops on is titled, “Practice Implications”. There bullets of text under the title.]

Okay. Again, just to try to keep on time.  So, practice implications. We want to make sure we have service delivery that really involves the families. That's going to lead to better generalization of skills of whatever the child is working on and have an impact down the road for the kids. Another thing I talk about when I teach is, front loading the services, trying to provide as much services as possible and involve the parents in those services. That's going to have a bigger bang for your buck than trying to do stuff later on. We also want to make sure that early intervention providers have specialized experience working with, -and really this area needs a lot more research. There's not a whole lot of research looking at how much kids should be receiving for early intervention services. How does having a highly trained service provider, who is really experienced working with kids with hearing loss, how does that do compare to someone who has less experience working with kids with hearing loss? That's still an open question and we are currently looking into that more.

[PowerPoint slide appears with a wave graph. At the bottom of the slide, there is text that says, “What can we expect from children who are hard of hearing?”.]

And then, finally, I want to talk about what we can expect from these kids. Where should the bar be? What should we expect from these kids with hearing loss, who are hard of hearing?

[A PowerPoint slide appears, titled, “How do children who are hard of hearing compare to children with typical hearing?”. There is a diagram on the slide that is covered by a large text box that states the conclusion from the diagram.]

So, one of our big questions was, how do these children do, compared to children with typical hearing? And, so, this shows the children from 2 to 6 years of age. The black bars show you the children with typical hearing. The white circles show the children who are hard of hearing in the study. And this is a composite language score, global language measure, so receptive and expressive language put together. And what we found was the hash region, again, shows the standard score norms for our standardized test. So, anything within that hash region indicates average performance on the standardized test. And, so, you can see the kids who are hard of hearing, are well within the average range when we look at them compared to just a standardized test norms. But when we compare them to this group of children who are matched on socioeconomic status and age and income level, we find a significant difference at every age, and by 5 and 6 years of age, we see almost a one standard deviation difference. So that little D there indicates the effect size or how much of a difference there was between the two groups. So, when we're comparing the children who are hard of hearing to the kids who are in their own classrooms, -because the typical hearing kids in our study, we actually went out and recruited children from the same towns as the kids who are hard of hearing. When we're making that comparison, these children do seem to be at risk for language delays. 

[PowerPoint slide appears, titled, “Practice Implications”. There are bullets of information below the title.]

So, we did find that, but that doesn't mean we can't set the bar high for these kids. So, the big picture here is, getting them as much language input as possible, in whatever format we can, be it gesture, sign, spoken language, that we want to still set the bar high for these kids. Because we have found plenty of kids in our study who are doing excellent, doing well within the average range, or even better than that. So, we found that lots of the kids in the study are performing like their peers with typical hearing, so we need to have high expectations for achievement. Just having a score in the average range on the standardized tests, -I don't feel like that's enough for these kids. They should be able to achieve the same levels as the kids in their own schools. So, really, we can't be complacent. We need to keep providing as much language access as we can. And what we're currently doing now, -so the data presented up to age 6. We're now looking at these kids in second and fourth grade. So, we're continuing to see what's the impact on literacy and socialization. I'm getting the flag. I better hurry up.

[PowerPoint slide appears with a photo of a child’s ear with a cochlear implant, a photo of a note, and a photo of a child holding up a document.]

Okay, so last thing I want to show is just this idea of setting the bar high. This was a child who was in our study, and she had to do a school project in first grade, all the kids in her school, her first-grade class, had to do it, where they had to talk about, what's your favorite thing about yourself? What do you really like about yourself? And she chose her ears. She said, the best part about me is my ears. I use my ears to hear. I love my ears because they are unique. And she had her teacher take a picture of her, and then presented it to the class.

[A PowerPoint slide appears with the photo of the child with the document from the previous slide. There are also images of graphs and a table.]

And just to point out, this is one child. Great language input from her parents. She wore the hearing aids consistently, and she ended up, by first grade, she was performing above average in terms of her reading skills, print awareness, her grammar skills, and then within the average range on vocabulary and speech. So, again, we can really set the bar high for these kids and not have, -we can have high goals for them. Okay. I'm going to skip this one because I know I'm running out of time. Okay. 

[Walker skips through a couple of slides.]

Sorry to skip ahead.

[A PowerPoint slide appears, titled, “Where are we know?”. There are images of kids and adults on this slide. At the bottom of the PowerPoint, the text “Outcomes of Children with Hearing Loss, a study of children ages birth to six”.]

So, just to kind of tie things up. Like I said, the outcomes of children with hearing loss study looked at the kids up to age 6.

[A PowerPoint slide describing “Future Research Directions.]

We are now looking at the kids into fourth grade and hope to continue to look at them into junior high. And look at what are the effects of -- cascading effects on literacy, psychosocial development, another study, if you have any interest in participating in the research, we're also looking at listening efforts. 

[A PowerPoint slide appears, with text that says, “What are the underlying causes of increased listening effort?”. There is a photo on the slide of a child looking frustrated with two large stacks of books.]

So how much effort do these kids have to put into listening and what are the underlying causes? And, so, I have some information on that that I can give you.

[A PowerPoint slide with three different columns, each titled respectively, “Who we need”, “What will happen”, and “What we offer”.]

[Walker begins to speed through slides as she describes them.]

If you want more information about the study, we have posters that are now available. We have our web page, the, so you can go to our web page and get information. If you are a service provider, we have brought some brochures and posters that I am happy to share with you and you can also go to our web page and get that information. Again, sorry that I'm hurrying through this so much. All right. Last of all, this is obviously not a one-woman show. This project required a whole lot of people. It takes a village. So, these are some of the members of our team that have supported us throughout the years and been a part of this project. Okay. Thank you.

[A PowerPoint slide that says, “Thank you!” with a photo of a child giving a thumbs up.]

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