Is Early Intervention Effective in Improving Spoken Language Outcomes of Children With Congenital Hearing Loss?

Coalition for Global Hearing Health Hearing Care Pathways Working Group: Guidelines for Clinical Guidance for Readiness and Development of Evidence-Based Early Hearing Detection and Intervention Programs

Editor's Note: The following article discusses the timely topic Clinical Guidance in the areas of Evidence-Based Early Hearing Detection and Intervention Programs. This article aims to discuss areas of services needed, guidance to countries/organizations attempting to initiate early hearing detection and intervention systems. Expert consensus and systematic/scoping reviews were combined to produce recommendations for evidence-based clinical practice. In Ear and Hearing, our long-term goal for the Point of View article is to stimulate the field's interest in and to enhance the appreciation of the author's area of expertise. Hearing is an important sense for children to develop cognitive, speech, language, and psychosocial skills. The goal of universal newborn hearing screening is to enable the detection of hearing loss in infants so that timely health and educational/therapeutic intervention can be provided as early as possible to improve outcomes. While many countries have implemented universal newborn hearing screening programs, many others are yet to start. As hearing screening is only the first step to identify children with hearing loss, many follow-up services are needed to help them thrive. However, not all of these services are universally available, even in high-income countries. The purposes of this article are (1) to discuss the areas of services needed in an integrated care system to support children with hearing loss and their families; (2) to provide guidance to countries/organizations attempting to initiate early hearing detection and intervention systems with the goal of meeting measurable benchmarks to assure quality; and (3) to help established programs expand and improve their services to support children with hearing loss to develop their full potential. Multiple databases were interrogated including PubMed, Medline (OVIDSP), Cochrane library, Google Scholar, Web of Science and One Search, ERIC, PsychInfo. Expert consensus and systematic/scoping reviews were combined to produce recommendations for evidence-based clinical practice. Eight essential areas were identified to be central to the integrated care: (1) hearing screening, (2) audiologic diagnosis and management, (3) amplification, (4) medical evaluation and management, (5) early intervention services, (6) family-to-family support, (7) D/deaf/hard of hearing leadership, and (8) data management. Checklists are provided to support the assessment of a country/organization's readiness and development in each area as well as to suggest alternative strategies for situations with limited resources. A three-tiered system (i.e., Basic, Intermediate, and Advanced) is proposed to help countries/organizations at all resource levels assess their readiness to provide the needed services and to improve their integrated care system. Future directions and policy implications are also discussed.

Family-Perceived Barriers and Facilitators Toward a Tele-Audiology Infant Diagnostic Testing Approach in Victoria, Australia

Background: Universal newborn hearing screening programs allow for early identification of congenital hearing loss. However, some families experience difficulties accessing diagnostic audiology services following a refer screen result. Methods: This study aimed to assess the opinions of families who had experienced infant diagnostic audiology assessments regarding a telehealth option for these appointments within Victoria, Australia. Families who attended in-person infant diagnostic audiology appointments were sent a questionnaire exploring their experiences of the service and their opinion regarding a proposed telehealth option for infant diagnostic audiology (50 responses received). These results were also compared to those of families who were surveyed following testing in 2020, where the audiologist conducted the appointment remotely to comply with COVID-19-related social distancing recommendations at the time (10 responses received). Results: There were not significant differences between the duration or number of appointments, perceived understanding of results, or concerns regarding a tele-audiology model between families who experienced face-to-face and tele-audiology infant diagnostic audiology appointments. Opinions of infant diagnostic audiology appointments utilizing telehealth technology were largely positive, and minimal technological difficulties were identified. Conclusion: Overall positive attitudes of many families with infant diagnostic appointment experiences toward a tele-audiology option of this service suggest that offering a telehealth model of appointments may be an appropriate model to improve service access for families requiring infant diagnostic audiology in Victoria.

Reliability and validity assessment of a survey: Measuring satisfaction with cochlear implant rehabilitation services for children in Jordan

BACKGROUND

Assessing parental satisfaction with healthcare services is crucial, particularly for parents and their children, who are the primary recipients of these services. In the context of Arabic-speaking parents, there is a notable absence of survey instruments tailored to measure their satisfaction. This study seeks to address this gap by validating a survey designed to evaluate parental satisfaction with rehabilitation services (RSs) provided to Jordanian children who have received cochlear implants (CIs).

METHODS

The study included 92 participants and followed a four-step methodology: 1) a literature review and expert input; 2) cognitive interviews, pilot testing, and test-retest reliability testing; 3) data collection; 4) validity and reliability assessments.

RESULTS

The survey's validity was confirmed. Expert input and cognitive interviews improved content validity, and factor analysis established construct validity by revealing six factors explaining 82.33% of the variance in the survey scale. Convergent and discriminant validity were confirmed (composite reliability >0.7 and average variance extracted value >0.5). Cronbach's α exceeded 0.8 for each factor and reached 0.855 for the total scale. Survey results showed reliance on speech therapy and audiology, varied rehabilitation durations, and progress. Parents expressed overall satisfaction, particularly influenced by technical quality and efficacy/outcome dimensions. Parents' recommendations to enhance satisfaction with RSs included financial support, improved service accessibility, enhanced service delivery, specialized education, and increased public awareness.

CONCLUSION

This study validates an Arabic satisfaction survey, emphasizing the significance of multidisciplinary, extended rehabilitation programs, skilled professionals, and positive outcomes. It emphasizes the necessity for improved access to specialized care and collaboration among healthcare, government, and media to shape parental perceptions of RSs. While the findings indicate overall satisfaction, they also reveal challenges faced by parents, highlighting the need for comprehensive support systems. These insights assist healthcare providers and policymakers in enhancing care quality and meeting the needs of CI children's families, thereby improving the RSs experience in Jordan.

Referral rate and false-positive rates in a hearing screening program among high-risk newborns

AIM

More studies exploring referral rates and false-positive rates are needed to make hearing screening programs in newborns better and cost-effective. Our aim was to study the referral and false-positivity rates among high-risk newborns in our hearing screening program and to analyze the factors potentially associated with false-positive hearing screening test results.

METHODS

A retrospective cohort study was done among the newborns hospitalized at a university hospital from January 2009 to December 2014 that underwent hearing screening with a two-staged AABR screening protocol. Referral rates and false-positivity rates were calculated and possible risk factors for false-positivity were analyzed.

RESULTS

4512 newborns were screened for hearing loss in the neonatology department. The referral rate for the two-staged AABR-only screening was 3.8% with false-positivity being 2.9%. Our study showed that the higher the birthweight or gestational age of the newborn, the lower the odds of the hearing screening results being false-positive, and the higher the chronological age of the infant at the time of screening, the higher the odds of the results being false-positive. Our study did not show a clear association between the mode of delivery or gender and false-positivity.

CONCLUSION

Among high-risk infants, prematurity and low-birthweight increased the rate of false-positivity in the hearing screening, and the chronological age at the time of the test seems to be significantly associated with false-positivity.

Spoken Expressive Vocabulary in 2-Year-Old Children with Hearing Loss: A Community Study

Through a cross-sectional community study of 2044 children aged 2 years, we (1) examine the impact of hearing loss on early spoken expressive vocabulary outcomes and (2) investigate how early intervention-related factors impact expressive vocabulary outcomes in children with hearing loss predominantly identified through universal newborn hearing screening. We used validated parent/caregiver-reported checklists from two longitudinal cohorts (302 children with unilateral or bilateral hearing loss, 1742 children without hearing loss) representing the same population in Victoria, Australia. The impact of hearing loss and amplification-related factors on vocabulary was estimated using g-computation and multivariable linear regression. Children with versus without hearing loss had poorer expressive vocabulary scores, with mean scores for bilateral loss 0.5 (mild loss) to 0.9 (profound loss) standard deviations lower and for unilateral loss marginally (0.1 to 0.3 standard deviations) lower. For children with hearing loss, early intervention and amplification by 3 months, rather than by 6 months or older, resulted in higher expressive vocabulary scores. Children with hearing loss demonstrated delayed spoken expressive vocabulary despite whole-state systems of early detection and intervention. Our findings align with calls to achieve a 1-2-3 month timeline for early hearing detection and intervention benchmarks for screening, identification, and intervention.

[Analysis of clinical audiological characteristics in 868 children referred from maternal and child institutions]

Objective:To investigate the clinical audiological characteristics of children referred from maternal and child institutions and analyze the high risk factors of hearing loss, so as to provide scientific basis for further improvement of children's ear and hearing care. Methods:The subjects of this study were 868 children who were referred by maternal and child institutions in Beijing to the otology outpatient of Beijing Tongren Hospital, Capital Medical University for hearing diagnosis. All subjects underwent acoustic immittance, auditory brainstem response, distortion products otoacoustic emission and other audiological tests. Children were divided into groups according to the age of diagnosis: 0-<3 months group（242 cases）, 3-<6 months group（328 cases）, 6-<12 months group（180 cases）, ≥12 months group（118 cases）, the results of hearing diagnosis, hearing loss degree and types, the relationship between high risk factors and hearing loss in each group were compared and analyzed. Results:The age of diagnosis of 868 children was（7.13±8.29） months. 488 cases with hearing loss accounted for 56.22% and 380 cases with normal hearing accounted for 43.78%. Proportion of different degree of hearing loss of 792 ears from high to low was as follows: mild, 366 ears（46.21%）; moderate, 214 ears（27.02%）; severe, 151 ears（19.07%）; profound, 61 ears（7.70%）. There were statistically significant differences in the proportion of different hearing loss degree among 0-<3 months group, 3-<6 months group, 6-<12 months group and ≥12 months group（P<0.001）. Pairwise comparison between groups showed that the proportion of mild hearing loss of 0-<3 months group was higher than that in the other three groups（P<0.05）, there was no significant difference of moderate hearing loss among all groups（P>0.05）, the proportion of severe hearing loss of ≥12 months group was higher than that of 0-<3 months group（P<0.05）. The proportion of profound hearing loss with 0-<3 months group was lower than the other three groups（P<0.05）. In 792 ears with hearing loss, sensorineural hearing loss accounted for 67.42%, conductive hearing loss accounted for 20.71% and mixed hearing loss accounted for 11.87%. Among 98 cases with high risk factors for hearing loss, 58 cases（59.18%） were diagnosed with hearing loss. The incidence of hearing loss with high risk factors ranked from high to low was: craniofacial malformation（93.75%）, family history/congenital genetic syndrome（61.11%）, neonatal intensive care unit（NICU） hospitalization（46.43%） and others（20.00%）. Conclusion:Referrals from maternal and child institutions play an important role in the early detection of children with mild to moderate sensorineural hearing loss. Children with craniofacial malformation, family history/congenital genetic syndrome, hospitalization history of NICU and other high risk factors have a high incidence of hearing loss and should be attached with great importance.

Younger Age at Cochlear Implant Activation Results in Improved Auditory Skill Development for Children With Congenital Deafness

PURPOSE

The U.S. Food and Drug Administration indications for cochlear implantation in children is currently 9 months of age and older for children with bilateral profound sensorineural hearing loss (SNHL). Studies have shown that earlier activation of a cochlear implant (CI) can lead to better spoken language outcomes. As auditory skills are a precursor to the development of spoken language, this study was developed to investigate the influence of age at CI activation on auditory skill acquisition in young children. A secondary aim was to describe the auditory skills of children implanted prior to 9 months of age as compared to children with older ages of activation.

METHOD

Functional Listening Index (FLI) scores obtained during routine clinical visits were reviewed for 78 pediatric CI recipients with congenital bilateral profound hearing loss who were activated before 2 years of age. A linear mixed-effects model assessed the effect of age at CI activation on cumulative FLI scores over time.

RESULTS

There was a significant interaction between age at activation and chronological age at the time of evaluation, indicating that children with earlier access to sound achieved a greater number of auditory skills than those with later CI activations when measured at the same chronological age. Children activated before the age of 9 months approximated scores expected of children with typical hearing, whereas children activated between 9 and 24 months of age did not.

CONCLUSIONS

Younger age at CI activation is associated with increased auditory skills over time. Children who undergo cochlear implantation and CI activation before 9 months achieve more auditory skills by 4 years of age than children who are activated at later ages. These data suggest that reducing the approved age at cochlear implantation for children with congenital bilateral profound SNHL may support optimal auditory skill acquisition.

Vocabulary Outcomes for 5-Year-Old Children Who Are Deaf or Hard of Hearing: Impact of Age at Enrollment in Specialized Early Intervention

The aims of this study were to examine vocabulary scores of 5-year-old children who are deaf or hard of hearing (DHH), as well as the impact of early enrollment in specialized intervention on vocabulary outcomes. Receptive and expressive vocabulary scores were analyzed for 342 five-year-old children who are DHH enrolled in specialized listening and spoken language intervention programs. Regression analyses were utilized to examine the effects of age at enrollment on vocabulary outcomes. Overall, participants achieved scores within normal test limits on receptive and expressive measures of vocabulary. Children who enrolled in intervention prior to 28 months of age had better vocabulary skills at 5 years old. The findings support that children who are DHH can understand and produce vocabulary at skill levels commensurate with their typically hearing peers, regardless of severity of hearing loss. Results highlight the crucial impact of specialized programs on children's lexical readiness to participate in general education settings by kindergarten.

Expressive vocabulary development in children with moderate hearing loss - the impact of auditory variables and early consonant production

In this study, the early expressive vocabulary development was investigated in a group of children with moderate hearing loss (HL). Size and development of expressive vocabulary from 18 30 months were analyzed and compared to a group of children with normal hearing (NH). For the children with HL, the impact of auditory variables on number of words were examined. The relationship of early consonant production to number of words produced of both groups were examined and the phonological complexity of reported words was compared between the groups. The results showed that children with HL (n = 8) produced a similar number of words as the NH (n = 8) at 18 months, but fewer at 24 and 30 months. Hours of HA use showed significant correlations to number of words. The number of different true consonants at 18 months for the whole group showed a significant relationship to number of words produced at 24 months. No significant differences were found between children with HL and NH children regarding phonological complexity of reported words. The findings indicate that the children born with moderate HL who were fitted with hearing aids (HAs) before 6 months of age are at risk in their development of expressive vocabulary. Full-time use of HAs and monitoring of early consonant use should be encouraged in the early intervention of this target group.

Cost-effectiveness analysis of hearing screening program for primary school children in southern Iran, Shiraz

BACKGROUND

Hearing loss is the second most common chronic disease, the diagnosis and treatment of which can be faster through screening. In addition, early interventions will save significant costs for the education and health systems. Therefore, the present study aimed to evaluate the cost-effectiveness of hearing screening for primary school children in Shiraz.

METHODS

This cross-sectional economic evaluation of cost-effectiveness was conducted from the perspective of the health system. The study population comprised all seven-year-old children participating in the screening program in Shiraz. The present study dealt only with direct costs. The expected costs and outcomes, as well as the ICER index were estimated using the decision tree model. The study outcomes included averted disability-adjusted life years (DALY) and true identification of hearing loss cases. The robustness of the results was evaluated using the one-way sensitivity analysis. The TreeAge 2020 and Excel 2016 software were also used to analyze the collected data.

RESULTS

The hearing screening data obtained during 6 years (2015-2020) showed that every year, an average of 22,853 children in Shiraz were examined for hearing, of which 260 were true positive (%1.1). The costs of screening and lack of screening were estimated at $30.32 Purchasing Power Parity (PPP) and $13.75 PPP per child, respectively. The averted DALY due to performing hearing screening was estimated at 7 years for each child. The ICER was positive and equal to $ 0.06 PPP for the identified cases and $ 2.37 PPP per averted DALY. The sensitivity analysis confirmed the robustness of the results.

CONCLUSIONS

According to the results, although hearing screening for primary school children had more costs and effectiveness, it was considered cost-effective. Therefore, universal screening with high quality and accuracy is recommended.

Determination of language performance by discriminant function analysis in Mandarin-speaking preschoolers with auditory neuropathy spectrum disorder

OBJECTIVE

Characteristics of the audiological performance of children with auditory neuropathy spectrum disorder (ANSD) have been identified; however, studies regarding factors influencing their language development, especially those related to aural-oral rehabilitation, are relatively few. This study aimed to investigate classification functions among the factors regarding audiological, interventional (rehabilitation) and demographic variables that can help determine group membership in language performance for Mandarin-speaking preschoolers with ANSD.

METHODS

Children with ANSD aged 3-6 years (n = 27) enrolled in an auditory-verbal therapy were recruited. The combination of factors that could be used to predict memberships of children regarding whether they achieved age-appropriate language performance or were at risk of language delay were explored using discriminant function analysis.

RESULTS

Maternal education level, age at initial hearing aid fitting, and duration of rehabilitation were all significant factors in predicting the membership of children with ANSD and whether they could achieve an age-appropriate language level or were at risk for language delay. The correct rate for predicting the memberships ranged from 70.4% to 83.3%. Duration of rehabilitation accounted for the greatest effect on discriminant membership regarding achieving age-appropriate language performance and being at risk of language delay. Effect of maternal education level tended to centralize on language comprehension.

CONCLUSIONS

Differences were observed in the quantifiable effects of predictors in discriminant functions for language ability domains. Except for using suitable hearing devices, adequate duration of enrollment in aural and oral rehabilitation would also be important for children with ANSD to develop better language abilities.

Early detection of hearing loss for infants in Western Australia: Comparison to international benchmarks

AIM

To assess the degree to which timely audiological assessment of congenital hearing loss is achieved at our institution - Perth Children's Hospital, Western Australia, and to review cases which breached this timeframe in order to address barriers to timely assessment. The benchmark used to determine timely assessment is that set out by The Joint Committee on Infant Hearing (JCIH) in which diagnostic audiological testing occurs by three months of age for those who do not pass newborn hearing screening.

METHODS

A retrospective chart review of infants who underwent diagnostic auditory assessment at Perth Children's Hospital between 2016-2019. A total of 151 children were identified as meeting the inclusion criteria and their medical files were reviewed. Time to first dABR was the time point for whether testing was achieved within the 3 month timeframe.

RESULTS

Of the 151 children who underwent dABR assessments, 1 was identified as having breached the 90 day time limit (tested on day 91) for which no valid reason for delay could be identified. The timely delivery of dABR assessments in 99.3% of cases within this cohort compares favourably with the literature.

CONCLUSIONS

Conclusion Timely diagnostic audiological assessment is achievable for children with congenital hearing loss. The reasons for patients breaching this timeframe are explored in the paper along with factors which may help avoid delays.

Language development in infants with hearing loss: Benefits of infant-directed speech

The majority of infants with permanent congenital hearing loss fall significantly behind their normal hearing peers in the development of receptive and expressive oral communication skills. Independent of any prosthetic intervention ("hardware") for infants with hearing loss, the social and linguistic environment ("software") can still be optimal or sub-optimal and so can exert significant positive or negative effects on speech and language acquisition, with far-reaching beneficial or adverse effects, respectively. This review focusses on the nature of the social and linguistic environment of infants with hearing loss, in particular others' speech to infants. The nature of this "infant-directed speech" and its effects on language development has been studied extensively in hearing infants but far less comprehensively in infants with hearing loss. Here, literature on the nature of infant-directed speech and its impact on the speech perception and language acquisition in infants with hearing loss is reviewed. The review brings together evidence on the little-studied effects of infant-directed speech on speech and language development in infants with hearing loss, and provides suggestions, over and above early screening and external treatment, for a natural intervention at the level of the carer-infant microcosm that may well optimize the early linguistic experiences and mitigate later adverse effects for infants born with hearing loss.

Newborn Hearing Screening Benefits Children, but Global Disparities Persist

There is substantial evidence that newborn hearing screening (NHS) reduces the negative sequelae of permanent childhood hearing loss (PCHL) if performed in programs that aim to screen all newborns in a region or nation (often referred to as Universal Newborn Hearing Screening or UNHS). The World Health Organization (WHO) has called in two resolutions for the implementation of such programs and for the collection of large-scale data. To assess the global status of NHS programs we surveyed individuals potentially involved with newborn and infant hearing screening (NIHS) in 196 countries/territories (in the following text referred to as countries). Replies were returned from 158 countries. The results indicated that 38% of the world's newborns and infants had no or minimal hearing screening and 33% screened at least 85% of the babies (hereafter referred to as UNHS). Hearing screening programs varied considerably in quality, data acquisition, and accessibility of services for children with PCHL. In this article, we summarize the main results of the survey in the context of several recent WHO publications, particularly the World Report on Hearing, which defined advances in the implementation of NHS programs in the Member States as one of three key indicators of worldwide progress in ear and hearing care (EHC).

Benefits of Parent Training in the Rehabilitation of Deaf or Hard of Hearing Children of Hearing Parents: A Systematic Review

The present study is a systematic review on the effectiveness of Parent Training (PT) and coaching in deaf and hard of hearing (DHH) rehabilitation programs which reviews and synthesizes the existing body of evidence to assess the benefits of these programs in enhancing parents' sensitivity, responsivity and promoting language development in DHH children during the first years after HA fitting or CI activation. Five published studies met the Population, Intervention, Comparison and Outcomes (PICO) inclusion criteria and were eligible to be included, but heterogeneity in terms of the study design, interventions and outcomes did not allow for performing a meta-analysis. All included studies shared the view that a parent's learning is a circular (rather than frontal) process, and the results appear promising in terms of enhancing parents' responsiveness and promoting DHH child language development. Nevertheless, the available evidence was judged to not be robust enough due to limitations in the studies' designs. Further high-quality evidence is needed to evaluate the true degree of clinical value and the cost effectiveness of PT programs aimed at increasing parents' responsiveness to their DHH children.

Coaching Caregivers of Children who are Deaf or Hard of Hearing: A Scoping Review

Caregiver coaching is an expected practice in early intervention. However, little is known about coaching with caregivers of children who are deaf or hard of hearing, receiving services for listening and spoken language (LSL). A systematic review of 7 databases, the gray literature, and consultation with 7 expert LSL practitioners yielded 506 records for full-text review, 22 of which were ultimately included in the review. Our findings are presented as 3 themes: coaching practices, training for coaching, and effectiveness of coaching. Eight models of coaching were identified in the literature, from which we identified commonalities to propose a consolidated model that illustrates the recommendations and process of caregiver coaching found in the LSL literature.

Mild matters: parental insights into the conundrums of managing mild congenital hearing loss

OBJECTIVE

To explore and describe parental experiences related to the management of mild bilateral congenital hearing loss in children.

DESIGN

Using qualitative methods, we conducted semi-structured interviews with parents/caregivers until saturation of themes was achieved. We analysed transcripts using inductive content analysis.

STUDY SAMPLE

Caregivers of children under 3-years-old with mild bilateral sensorineural hearing loss.

RESULTS

We interviewed 12 parents. Parental perception of advice regarding hearing aid fitting was varied; almost all children were offered hearing aids. Perceived positives related to hearing aids: feeling empowered that action has been taken; improvements in the child's hearing perception and; facilitation of behavioural management. Perceived negatives of hearing aid use: difficulties with compliance resulting in parental frustration and guilt, damage/loss of equipment, discomfort, parental discord, altered quality of natural sound and potential bullying/stigma. Some parents were ambivalent about the effect of the hearing aids. Where hearing aids were offered and not fitted, there was significant ongoing uncertainty, and the family carried the burden of their decision.

CONCLUSIONS

There was a wide variation in perceived advice regarding early hearing aid fitting in children with mild bilateral hearing loss. We identified parental perceptions of positive/negative impacts of hearing aid fitting and potential perceived harms from not fitting.

Delivery of audiological diagnoses for infants: a linguistic analysis of clinical communication

OBJECTIVE

To describe and analyse the linguistic structure of audiological diagnoses for infants, to determine ways to optimise the delivery of diagnostic information to parents during this typically emotive time.

DESIGN

This study analysed the linguistic structure of audio-recorded infant diagnostic appointments.

STUDY SAMPLE

Nine appointments conducted by four experienced paediatric audiologists were analysed.

RESULTS

Diagnoses of normal hearing were delivered explicitly and in a straightforward manner. Positive aspects of this outcome were highlighted, and audiologists used the pronoun "we," conveying a feeling of teamwork. In contrast, when a hearing loss was diagnosed, the diagnosis included disfluencies and the use of hedging, although positive aspects were also emphasised. In these cases, audiologists used the pronoun "I," thereby taking ownership of the results. Differences in the topics raised by audiologists and parents highlighted a mis-match between the information provided and the information requested. Topics addressed by audiologists were primarily medical and procedural, whereas parents were concerned with causes, treatments and experiential information.

CONCLUSIONS

The use of the above linguistic strategies may serve to minimise the significance and impact of the diagnosis. Whilst the data are unable to be generalised to other contexts, the study has generated in-depth and nuanced information about diagnosis delivery.

Listening Difficulties of Children With Cochlear Implants in Mainstream Secondary Education

OBJECTIVES

Previous research has shown that children with cochlear implants (CIs) encounter more communication difficulties than their normal-hearing (NH) peers in kindergarten and elementary schools. Yet, little is known about the potential listening difficulties that children with CIs may experience during secondary education. The aim of this study was to investigate the listening difficulties of children with a CI in mainstream secondary education and to compare these results to the difficulties of their NH peers and the difficulties observed by their teachers.

DESIGN

The Dutch version of the Listening Inventory for Education Revised (LIFE-R) was administered to 19 children (mean age = 13 years 9 months; SD = 9 months) who received a CI early in life, to their NH classmates (n = 239), and to their teachers (n = 18). All participants were enrolled in mainstream secondary education in Flanders (first to fourth grades). The Listening Inventory for Secondary Education consists of 15 typical listening situations as experienced by students (LIFEstudent) during class activities (LIFEclass) and during social activities at school (LIFEsocial). The teachers completed a separate version of the Listening Inventory for Secondary Education (LIFEteacher) and Screening Instrument for Targeting Educational Risk.

RESULTS

Participants with CIs reported significantly more listening difficulties than their NH peers. A regression model estimated that 75% of the participants with CIs were at risk of experiencing listening difficulties. The chances of experiencing listening difficulties were significantly higher in participants with CIs for 7 out of 15 listening situations. The 3 listening situations that had the highest chance of resulting in listening difficulties were (1) listening during group work, (2) listening to multimedia, and (3) listening in large-sized classrooms. Results of the teacher's questionnaires (LIFEteacher and Screening Instrument for Targeting Educational Risk) did not show a similar significant difference in listening difficulties between participants with a CI and their NH peers. According to teachers, NH participants even obtained significantly lower scores for staying on task and for participation in class than participants with a CI.

CONCLUSIONS

Although children with a CI seemingly fit in well in mainstream schools, they still experience significantly more listening difficulties than their NH peers. Low signal to noise ratios (SNRs), distortions of the speech signal (multimedia, reverberation), distance, lack of visual support, and directivity effects of the microphones were identified as difficulties for children with a CI in the classroom. As teachers may not always notice these listening difficulties, a list of practical recommendations was provided in this study, to raise awareness among teachers and to minimize the difficulties.

Investigating the Effect of Hearing Aid Use on the Balance Status of Children with Severe to Profound Congenital Hearing Loss Using the Pediatric Clinical Test of Sensory Interaction for Balance

BACKGROUND

 Since the hearing and vestibular organs are close to each other, the correlation between hearing and balance is one of the principal issues, especially in people with hearing loss.

PURPOSE

 In this study, the effect of the auditory system on human balance performance was investigated by comparing the balance status of hearing-impaired children in the aided and unaided situations.

RESEARCH DESIGN

 In this cross-sectional study a group of children were assigned the task to compare the balance sways in two aided and unaided situations.

STUDY SAMPLING

 A total of 90 children aged 7 to 10 years with severe to profound congenital hearing loss and the healthy vestibular system of both genders served as the research population.

DATA COLLECTION AND ANALYSIS

 After a complete evaluation of the hearing and vestibular system and validation of the hearing aid performance, body sway was recorded using the pediatric clinical test of sensory interaction for balance in aided and unaided situations in the presence of background noise from the speaker.

RESULTS

 According to this study, there was no difference in body sway in aided and unaided situations for conditions 1, 2, and 3. In comparison, in conditions 4, 5, and 6 of the test, there was a statistically significant difference in body sway between aided and unaided situations. However, there was no difference in the sway of the body in aided and unaided situations between girls and boys.

CONCLUSION

 According to this study, hearing aids can improve balance in challenging listening environments.

Stress in Parents of School-Age Children and Adolescents With Cochlear Implants

Parents of children with cochlear implants (CIs) face unique challenges in caring for their child, potentially fostering parental stress. Most studies of stress in parents of CI users do not examine stress specific to having a deaf and hard-of-hearing (DHH) child. This study compares general and condition-specific stress (via the Family Stress Scale) in 31 parents of CI users (8-16 years) to previously published samples of DHH children, and it examines child- and CI-related factors associated with parental stress. Parents of modern-day CI users reported significantly lower stress than parents of children using older-generation CI technology and similar levels of overall stress to parents of young children preimplantation. However, significant item-level differences emerged (e.g., communication, device management) pre- versus postimplant. Child temperament significantly predicted parental stress after controlling for other variables. Intervention strategies for children with CIs should engage a family systems approach to reduce parental stress and better support the child.

An audit of UK audiological practice in specialist paediatric oncology centres regarding hearing assessment of children at risk of ototoxicity due to chemotherapy

OBJECTIVE

Platinum-based chemotherapy drugs are associated with substantial ototoxicity. The hearing of children treated with these drugs should be closely monitored.

METHOD

A questionnaire was sent out to the 19 audiology departments associated with national paediatric cancer specialist centres in the UK looking at current practice in ototoxicity monitoring.

RESULTS

Responses were received from 17 of 19 centres (89 per cent). All offered some form of audiometric monitoring service. Extended high-frequency testing (9-20 kHz) was only utilised by 7 services (29 per cent). A majority of respondents were reluctant to consider self-test devices in paediatric ototoxicity monitoring (n = 9; 53 per cent). Provision of long-term audiological follow up is sporadic with only 4 (23 per cent) respondents keeping all children with normal hearing under review once treatment is completed.

CONCLUSION

While some good practice in paediatric ototoxicity was identified, opportunities exist to improve clinical practice and protocols, promote multidisciplinary team working and to utilise technologies such as extended high frequency and self-test audiometry.

Language Environments and Spoken Language Development of Children With Hearing Loss

This study examined the relationships between adult language input and child language production in regard to the quantity and diversity of spoken language, as well as children's knowledge of basic concepts and vocabulary. The quantity and diversity of language provided by teachers and parents were related to children's language output and knowledge. Language ENvironment Analysis technology audio-recorded the language environments of 26 preschool children with hearing loss over 2 days. The language samples were analyzed for quantity (adult word count, child vocalization count, and conversational turn count) and diversity (lexical diversity, syntactical complexity, and clausal complexity) of language. Results indicated a relationship between adult language input and child language production, but only in regard to the quantity of language. Significant differences between the teachers and parents were reported in regard to the diversity of adult language input. These results suggest that the language input provided by adults across environments (school versus home) is considerably different and warrants further investigation.

Associations between ethnicity, place of residence, hearing status of family and habilitation of children with hearing impairment

Background

Hearing parents tend to have a strong preference for their deaf and hard-of-hearing children to acquire adequate speech, as opposed to use of sign language. Research reports the contribution of many variables to speech acquisition by children with hearing loss (HL). Yet, little is known about the association between ethnicity, place of residence, and hearing status of family members and mode of communication of young people with HL. The purpose of the present study was to examine whether mode of communication of young people with HL is associated with ethnicity, place of residence, and hearing status of family members.

Method

Participants were young adults with sensory-neural severe to profound HL, either congenital or acquired prior to age 3. Only participants without additional disabilities were included. The data on participants were extracted from records of the Ministry of Labor, Social Affairs and Social Services in Israel. The data for each participant in the study included mode of communication, gender, use of assistive device, ethnicity, geographic place of residence, and presence of first-degree relatives with HL. Regarding participants with a cochlear implant (CI), age at implantation was documented as well.

Results

Chi-square tests revealed significant associations between mode of communication and all of the study variables. In addition, all the study variables made a significant contribution to mode of communication. Regarding ethnicity, most of the ultra-Orthodox participants used oral language, while the majority of Israeli-Arab participants used sign language. Regarding geographical place of residence, lower rates of oral language use were found in the northern and southern districts of Israel.

Conclusions

The findings of the present study underline the need for better monitoring of Israeli-Arab children with HL and children residing in peripheral areas in Israel and for improving access to habilitation services.

Music Training for Children With Sensorineural Hearing Loss Improves Speech-in-Noise Perception

Purpose A growing body of evidence suggests that long-term music training provides benefits to auditory abilities for typical-hearing adults and children. The purpose of this study was to evaluate how music training may provide perceptual benefits (such as speech-in-noise, spectral resolution, and prosody) for children with hearing loss. Method Fourteen children aged 6-9 years with prelingual sensorineural hearing loss using bilateral cochlear implants, bilateral hearing aids, or bimodal configuration participated in a 12-week music training program, with nine participants completing the full testing requirements of the music training. Activities included weekly group-based music therapy and take-home music apps three times a week. The design was a pseudorandomized, longitudinal study (half the cohort was wait-listed, initially serving as a passive control group prior to music training). The test battery consisted of tasks related to music perception, music appreciation, and speech perception. As a comparison, 16 age-matched children with typical hearing also completed this test battery, but without participation in the music training. Results There were no changes for any outcomes for the passive control group. After music training, perception of speech-in-noise, question/statement prosody, musical timbre, and spectral resolution improved significantly, as did measures of music appreciation. There were no benefits for emotional prosody or pitch perception. Conclusion The findings suggest even a modest amount of music training has benefits for music and speech outcomes. These preliminary results provide further evidence that music training is a suitable complementary means of habilitation to improve the outcomes for children with hearing loss.

Service accessibility for children with hearing loss in rural areas of the United States and Canada

OBJECTIVES

Children in rural areas have difficulty accessing the same services as their urban peers, which is a particular challenge in large countries such as the U.S. and Canada. Despite known problems providing services in rural areas, there is limited research investigating services for children with hearing loss living in rural areas. This scoping review examines the accessibility of services for children with hearing loss in rural U.S. and Canada.

METHODS

The search strategy included four databases and gray literature from 2008-2018. Eight government documents and 16 articles met the inclusion criteria and the main findings in the literature were themed.

RESULTS

Children with hearing loss, experienced difficulties accessing specialized services which influenced the timing of diagnosis of hearing loss, receiving hearing technology and accessing ongoing support. Families in rural areas also had access to less information about hearing loss than urban families. Managing funding and health insurance was also a challenge for families in rural areas.

CONCLUSION

The limited research in this area indicates that children with hearing loss in rural areas can experience barriers when accessing the same services as their urban peers. Limited service provision can negatively influence outcomes for children with hearing loss. Alternate service delivery such as teleintervention and visiting specialists can improve service provision in rural areas. Comprehensive research of the experience of children with hearing loss across states, provinces and territories would guide improvements to services for children with hearing loss in rural areas of the U.S. and Canada.

Auditory findings associated with Zika virus infection: an integrative review

Introduction

Possible associations between Zika virus infection and hearing loss were observed during the epidemic in the Americas.

Objective

To describe the auditory alterations, pathogenesis and recommendations for follow-up in individuals with prenatal or acquired Zika virus infection.

Methods

Bibliographic research conducted in March/2018–April/2019 at the main available databases. Article selection, data extraction and quality evaluation were carried out by two independent reviewers. Studies containing auditory evaluation of patients with congenital or acquired Zika virus infection; and/or hypotheses or evidences on the pathophysiology of auditory impairment associated with Zika virus; and/or recommendations on screening and follow-up of patients with auditory impairment by Zika virus were included.

Results

A total of 27 articles were selected. Sensorineural and transient hearing loss were reported in six adults with acquired Zika virus infection. Of the 962 studied children, 482 had microcephaly and 145 had diagnostic confirmation of Zika virus; 515 of the 624 children with auditory evaluation performed only screening tests with otoacoustic emissions testing and/or automated click-stimuli auditory brainstem response testing. Studies in prenatally exposed children were very heterogeneous and great variations in the frequency of altered otoacoustic emissions and automated click-stimuli auditory brainstem response occurred across the studies. Altered otoacoustic emissions varied from 0% to 75%, while altered automated click-stimuli auditory brainstem response varied from 0% to 29.2%. Sensorineural, retrocochlear or central origin impairment could not be ruled out. One study with infected mice found no microscopic damage to cochlear hair cells. Studies on the pathogenesis of auditory changes in humans are limited to hypotheses and recommendations still include points of controversy.

Conclusion

The available data are still insufficient to understand the full spectrum of the involvement of the auditory organs by Zika virus, the pathogenesis of this involvement or even to confirm the causal association between auditory involvement and virus infection. The screening and follow-up recommendations still present points of controversy.

Economic Evaluations of Childhood Hearing Loss Screening Programmes: A Systematic Review and Critique

BACKGROUND

Permanent childhood hearing loss is one of the most common birth conditions associated with speech and language delay. A hearing screening can result in early detection and intervention for hearing loss.

OBJECTIVES

To update and expand previous systematic reviews of economic evaluations of childhood hearing screening strategies, and explore the methodological differences.

DATA SOURCES

MEDLINE, Embase, the Cochrane database, National Health Services Economic Evaluation Database (NHS EED), the Health Technology Assessment (HTA) database, and Canadian Agency for Drugs and Technologies in Health's (CADTH) Grey matters.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Economic evaluations reporting costs and outcomes for both the intervention and comparator arms related to childhood hearing screening strategies.

RESULTS

Thirty evaluations (from 29 articles) were included for review. Several methodological issues were identified, including: few evaluations reported outcomes in terms of quality-adjusted life years (QALYs); none estimated utilities directly from surveying children; none included disutilities and costs associated with adverse events; few included costs and outcomes that differed by severity; few included long-term estimates; none considered acquired hearing loss; some did not present incremental results; and few conducted comprehensive univariate or probabilistic sensitivity analysis. Evaluations published post-2011 were more likely to report QALYs and disability-adjusted life years (DALYs) as outcome measures, include long-term treatment and productivity costs, and present incremental results.

LIMITATIONS

We were unable to access the economic models and, although we employed an extensive search strategy, potentially not all relevant economic evaluations were identified.

CONCLUSIONS AND IMPLICATIONS

Most economic evaluations concluded that childhood hearing screening is value for money. However, there were significant methodological limitations with the evaluations.

Parent-Implemented Communication Treatment for Infants and Toddlers With Hearing Loss: A Randomized Pilot Trial

Purpose Despite advances in cochlear implant and hearing aid technology, many children with hearing loss continue to exhibit poorer language skills than their hearing peers. This randomized pilot trial tested the effects of a parent-implemented communication treatment targeting prelinguistic communication skills in infants and toddlers with hearing loss. Method Participants included 19 children between 6 and 24 months of age with moderate to profound, bilateral hearing loss. Children were randomly assigned to the parent-implemented communication treatment group or a "usual care" control group. Parents and children participated in 26, hour-long home sessions in which parents were taught to use communication support strategies. The primary outcome measures were the Communication and Symbolic Behavior Scales (Wetherby & Prizant, 2003), a measure of child prelinguistic skills, and parental use of communication support strategies during a naturalistic play session. Results Parents in the treatment group increased their use of communication support strategies by 17%. Children in the treatment group made statistically significant more gains in speech prelinguistic skills ( d = 1.09, p = .03) as compared with the control group. There were no statistically significant differences in social and symbolic prelinguistic skills; however, the effect sizes were large ( d = 0.78, p = .08; d = 0.91, p = .10). Conclusions This study provides modest preliminary support for the short-term effects of a parent-implemented communication treatment for children with hearing loss. Parents learned communication support strategies that subsequently impacted child prelinguistic skills. Although these results appear promising, the sample size is very small. Future research should include a larger clinical trial and child-level predictors of response to treatment.

Does screening for congenital cytomegalovirus at birth improve longer term hearing outcomes?

Currently, the diagnosis of congenital cytomegalovirus (cCMV) infection in most highly resourced countries is based on clinical suspicion alone. This means only a small proportion of cCMV infections are diagnosed. Identification, through either universal or targeted screening of asymptomatic newborns with cCMV, who would previously have gone undiagnosed, would allow for potential early treatment with antiviral therapy, ongoing audiological surveillance and early intervention if sensorineural hearing loss (SNHL) is identified. This paper systematically reviews published papers examining the potential benefits of targeted and universal screening for newborn infants with cCMV. We found that the treatment of these infants with antiviral therapy remains controversial, and clinical trials are currently underway to provide further answers. The potential benefit of earlier identification and intervention (eg, amplification and speech therapy) of children at risk of later-onset SNHL identified through universal screening is, however, clearer.

Mild-moderate congenital hearing loss: secular trends in outcomes across four systems of detection

BACKGROUND

Universal newborn hearing screening (UNHS) targets moderate or greater hearing loss. However, UNHS also frequently detects children with mild loss that results in many receiving early treatment. The benefits of this approach are not yet established. We aimed to (i) compare language and psychosocial outcomes between four hearing loss detection systems for children aged 5-8 years with congenital mild-moderate hearing loss; (ii) determine whether age of detection predicts outcomes; and (iii) compare outcomes between children identified via well-established UNHS and the general population.

METHODS

Linear regression adjusted for potential confounding factors was used throughout. Via a quasi-experimental design, language and psychosocial outcomes were compared across four population-based Australian systems of hearing loss detection: opportunistic detection, born 1991-1993, n = 50; universal risk factor referral, born 2003-2005, n = 34; newly established UNHS, born 2003-2005, n = 41; and well-established UNHS, born 2007-2010, n = 21. In pooled analyses, we examined whether age of detection predicted outcomes. Outcomes were similarly compared between the current well-established UNHS system and typically developing children in the Early Language in Victoria Study, born 2003, n = 1217.

RESULTS

Age at diagnosis and hearing aid fitting fell steadily across the four systems. For moderate losses, mean expressive language (P for trend .05) and receptive vocabulary (P for trend .06) improved across the four systems, but benefit was not obvious for mild losses. In pooled analyses, diagnosis before age six months predicted better language outcomes for moderate losses. Children with mild-moderate losses exposed to well-established UNHS continue to experience expressive language scores well below children in the general population (adjusted mean difference -8.9 points, 95% CI -14.7 to -3.1).

CONCLUSIONS

Treatment arising from UNHS appears to be clearly benefitting children with moderate hearing losses. However, rigorous trials are needed to quantify benefits, versus costs and potential harms, of early aiding of children with mild losses.

Language Underperformance in Young Children Who Are Deaf or Hard-of-Hearing: Are the Expectations Too Low?

OBJECTIVE

(1) To examine language performance in the context of cognitive abilities in young children who are deaf or hard-of-hearing and (2) to identify factors associated with having a language underperformance, defined as a gap between the language standard score and the nonverbal IQ (NVIQ) standard score.

METHODS

Children 6 to 82 months of age with bilateral hearing loss were enrolled. Language performance was defined as a ratio of language skills relative to cognitive abilities with language underperformance defined as a ratio of language scores to NVIQ <0.85.

RESULTS

Among 149 children, approximately half had hearing loss that was clinically classified as mild or moderate, and over one-third received a cochlear implant. Participants had a mean NVIQ in the average range (95.4 [20.3]). Receptive language scores were significantly lower than their NVIQ by 10.6 points (p < .0001). Among children with NVIQs 80 to 100, 62.5% had receptive scores <85 and 50% had a language underperformance (ratio <0.85). Among children with NIVQs >100, 21.1% had receptive scores <85 with 42% having a language underperformance. Children with language underperformance (n = 61, 41.5%) were more likely to have more severe levels of hearing loss, lower socioeconomic status, and be nonwhite.

CONCLUSION

Many children early identified with hearing loss continue to demonstrate language underperformance, defined using their cognitive potential. Language deficits have a cascading effect on social functioning in children who are deaf or hard-of-hearing. This study highlights the need to understand a child's cognitive potential to adequately address language needs in existing intervention models.

Exploring reasons for late identification of children with early-onset hearing loss

INTRODUCTION

Several studies have shown that early identification of childhood hearing loss leads to better language outcomes. However, delays in the confirmation of hearing loss persist even in the presence of well-established universal newborn hearing screening programs (UNHS). The objective of this population-based study was to document the proportion of children who experienced delayed confirmation of congenital and early onset hearing loss in a UNHS program in one region of Canada. The study also sought to determine the reasons for delayed confirmation of hearing loss in children.

METHODS

Population level data related to age of first assessment, age of identification and clinical characteristics were collected prospectively for all children identified through the UNHS program. We documented the number of children who experienced delay (defined as more than 3 months) from initial audiologic assessment to confirmation of hearing loss. A detailed chart review was subsequently performed to examine the reasons for delay to confirmation.

RESULTS

Of 418 children identified from 2003 to 2013, 182 (43.5%) presented with congenital or early onset hearing loss, of whom 30 (16.5%) experienced more than 3 months delay from initial audiologic assessment to confirmation of their hearing disorder. The median age of first assessment and confirmation of hearing loss for these 30 children was 3.7 months (IQR: 2.0, 7.6) and 13.8 months (IQR: 9.7, 26.1) respectively. Close examination of the factors related to delay to confirmation revealed that for the overwhelming majority of children, a constellation of factors contributed to late diagnosis. Several children (n = 22; 73.3%) presented with developmental/medical issues, 15 of whom also had middle ear dysfunction at assessment, and 9 of whom had documented family follow-up concerns. For the remaining eight children, additional reasons included ongoing middle ear dysfunction for five children, complicated by family follow-up concerns (n = 3) and mild hearing loss (n = 1) and the remaining three children had isolated reasons related to family follow-up (n = 1) or mild hearing loss (n = 2).

CONCLUSION

Despite the progress made in the early detection of pediatric hearing loss since UNHS, a substantial number of children referred for early assessment can experience late confirmation and intervention. In particular, infants with developmental and/or medical issues including middle ear disorders are at particular risk for longer time to confirmation of hearing loss.

Introduction to the Special Session on Intervention and Outcomes of Children With Hearing Loss

PURPOSE

This research forum article introduces the special session on “Intervention and Outcomes of Children with Hearing Loss” presented at the HEaring Across the Lifespan (HEAL) Conference in 2014.

METHOD

The method involved a narrative summary of the key findings of two papers presented during the session.

RESULTS

Early intervention was effective in improving outcomes of children with significant bilateral hearing loss. Preliminary findings on children with mild or unilateral hearing loss showed communicative development on par with their normal-hearing peers.

CONCLUSION

Children with bilateral hearing loss benefited from early detection and intervention.