Literacy skills in children with cochlear implants: the importance of early oral language and joint storybook reading

Vocal and early speech development in Korean-acquiring children with hearing loss and typical hearing

This study investigated the vocal and early speech development of Korean-acquiring children with hearing loss (HL) who underwent early auditory amplification compared to their typical hearing (TH) counterparts. The research focused on phonological characteristics of child vocalisation based on samples collected from naturalistic home environments. One-day home recordings using a Language ENvironment Analysis (LENA) recorder were obtained from 6 children with HL and 12 children with TH who ranged from 17 to 23 months of age in Korean monolingual environments. Child volubility, canonical babbling ratio (CBR), consonant distributions, and utterance structures of vocalisations were evaluated through qualitative and quantitative analyses of vocalisation samples collected from LENA recordings. The findings revealed that children with HL displayed comparable vocalisation levels to children with TH, with no significant differences in volubility and CBR. In consonant and utterance shape inventories, noticeable quantitative and qualitative differences were observed between children with HL and those with TH. The study also suggested both universal and language-specific production patterns, revealing the early effects of ambient language on consonant distributions and utterance structures within their vocalisation repertoire. This study emphasised the role of auditory input and the importance of early auditory amplification to support speech development in children with HL.

The role of lexical and prosodic characteristics of mothers' child-directed speech for the early vocabulary development of Italian children with cochlear implants

BACKGROUND

Variability in the vocabulary outcomes of children with cochlear implants (CIs) is partially explained by child-directed speech (CDS) characteristics. Yet, relatively little is known about whether and how mothers adapt their lexical and prosodic characteristics to the child's hearing status (before and after implantation, and compared with groups with normal hearing (NH)) and how important they are in affecting vocabulary development in the first 12 months of hearing experience.

AIMS

To investigate whether mothers of children with CIs produce CDS with similar lexical and prosodic characteristics compared with mothers of age-matched children with NH, and whether they modify these characteristics after implantation. In addition, to investigate whether mothers' CDS characteristics predict children's early vocabulary skills before and after implantation.

METHODS & PROCEDURES

A total of 34 dyads (17 with NH, 17 with children with CIs; ages = 9-32 months), all acquiring Italian, were involved in the study. Mothers' and children's lexical quantity (tokens) and variety (types), mothers' prosodic characteristics (pitch range and variability), and children's vocabulary skills were assessed at two time points, corresponding to before and 1 year post-CI activation for children with CIs. Children's vocabulary skills were assessed using parent reports; lexical and prosodic characteristics were observed in semi-structured mother-child interactions.

OUTCOMES & RESULTS

Results showed that mothers of children with CIs produced speech with similar lexical quantity but lower lexical variety, and with increased pitch range and variability, than mothers of children with NH. Mothers generally increased their lexical quantity and variety and their pitch range between sessions. Children with CIs showed reduced expressive vocabulary and lower lexical quantity and variety than their peers 12 months post-CI activation. Mothers' prosodic characteristics did not explain variance in children's vocabulary skills; their lexical characteristics predicted children's early vocabulary and lexical outcomes, especially in the NH group, but were not related to later language development.

CONCLUSIONS & IMPLICATIONS

Our findings confirm previous studies on other languages and support the idea that the lexical characteristics of mothers' CDS have a positive effect on children's early measures of vocabulary development across hearing groups, whereas prosodic cues play a minor role. Greater input quantity and quality may assist children in the building of basic language model representations, whereas pitch cues may mainly serve attentional and emotional processes. Results emphasize the need for additional longitudinal studies investigating the input received from other figures surrounding the child and its role for children's language development.

WHAT THIS PAPER ADDS

What is already known on the subject Mothers' CDS is thought to facilitate and support language acquisition in children with various language developmental trajectories, including children with CIs. Because children with CIs are at risk for language delays and have acoustic processing limitations, their mothers may have to produce a lexically simpler but prosodically richer input, compared to mothers of children with NH. Yet, the literature reports mixed findings and no study to our knowledge has concurrently addressed the role of mothers' lexical and prosodic characteristics for children's vocabulary development before implantation and in the first 12 months of hearing experience. What this study adds to the existing knowledge The study shows that mothers of children with CIs produce input of similar quantity but reduced variety, and with heightened pitch characteristics, compared to mothers of children with NH. There was also a general increase in mothers' lexical quantity and variety, and in their pitch range, between sessions. Only their lexical characteristics predicted children's early vocabulary skills. Their lexical variety predicted children's expressive vocabulary and lexical variety only in the NH group. What are the practical and clinical implications of this work? These findings expand our knowledge about the effects of maternal input and may contribute to the improvement of early family-centred intervention programmes for supporting language development in children with CIs.

Home Literacy Experiences and Shared Reading Practices: Preschoolers With Hearing Loss

Home literacy experiences and observed parent and child behaviors during shared book reading were investigated in preschool-age children with hearing loss and with typical hearing to examine the relationships between those factors and children's language skills. The methods involved parent-reported home literacy experiences and videotaped parent-child dyads during shared book reading. Children's language skills were tested using the Preschool Language Scale-4. The results indicated significant differences between groups for home literacy experiences and observed parent and child behaviors. Parents of children with hearing loss were found to read more frequently to their children than parents of children with typical hearing, yet scored lower for literacy strategies and teaching techniques compared to parents of children with typical hearing. Children with hearing loss scored lower in interactive reading behaviors compared to children with typical hearing. For children with hearing loss, frequency of book reading and child interactive reading behaviors were strong predictive factors for children's language skills. These results suggest that families of children with hearing loss would benefit from professional support as they read storybooks to their children. Similarly, children with hearing loss should be encouraged to be more interactive during shared book reading.

Developing a programme for training phonological awareness and assessment of its effectiveness on reading skills of elementary first graders with cochlear implant

Background

The current study aimed to develop a comprehensive phonological awareness intervention to train all levels of phonological awareness skills and to investigate its effect on the reading abilities of cochlear implanted children.

Materials and Methods

This study was the single-subject intervention. Phonological awareness intervention programme was developed and validated by experts' opinions. Six elementary first graders with cochlear implants and weak or delayed reading development, in 5-7-year-old range, were trained in phonological awareness skills. 'Auditory test of phonological awareness skills' was used to evaluate the subjects' phonological awareness skills. Nama reading test was also used to determine the level of reading performance.

Results

The results showed that all six subjects with cochlear implants had improvements of both phonological awareness skills and reading skills after participating in the phonological awareness intervention programme. This improvement was not only observed immediately after intervention but was also preserved in follow-up.

Conclusion

The findings of this study demonstrated the importance of planning an intervention programme about phonological awareness skills for elementary first graders with cochlear implant, and the important role of such an intervention programme in improving their performance in phonological awareness tasks, and then in reading tasks consequently. The importance of improvement in these skills could considerably affect these children's linguistic and psychological abilities, which may facilitate their education at higher grades.

Parenting Stress, Self-Efficacy, and Involvement: Effects on Spoken Language Ability Three Years After Cochlear Implantation

OBJECTIVE

This study evaluated associations among parenting stress, self-efficacy, and involvement in relation to spoken language outcomes in young children 3 years following cochlear implantation.

STUDY DESIGN

Cross-sectional.

SETTING

Six university tertiary medical centers.

PATIENTS

One hundred sixty-four young children with bilateral, severe-to-profound sensorineural hearing loss who had 3 years of experience with a CI; children with substantial cognitive impairments were excluded from the study.

MAIN OUTCOME MEASURESS

Family Stress Scale (FSS), Scale of Parental Involvement and Self-Efficacy (SPISE), Oral and Written Language Scales (OWLS).

RESULTS

Correlations were of moderate strength between FSS scores and SPISE scores (Parental Self-Efficacy, r = -0.45, p < 0.01, Parental Involvement r = -0.32, p < 0.01). As hypothesized, parents reporting higher levels of stress reported lower perceptions of self-efficacy and involvement. In addition, results showed that family stress had a direct, negative effect on spoken language (-4.43 [95% confidence interval: -6.97; -1.89]). After controlling for maternal education and activation age, parental self-efficacy mediated the negative effect between family stress and spoken language (indirect effect = -1.91 [3.45; -0.69]; proportion mediated = 0.43). No mediating effects were found for parental involvement.

CONCLUSIONS

These findings highlight the need for parenting interventions that focus on reducing stressors and increasing parents' perceptions of self-efficacy in families of children using cochlear implants. Integration of mental health screening and tailored parenting interventions in CI clinics may increase parental self-efficacy and involvement, with measurable benefits in the child's use of spoken language.

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.

The Impact of Family Environment on Language Development of Children With Cochlear Implants: A Systematic Review and Meta-Analysis

OBJECTIVES

The authors conducted a systematic review of the literature and meta-analyses to assess the influence of family environment on language development in children with cochlear implants.

DESIGN

The Pubmed, excerpta medica dataBASE (EMBASE), Education Research Information Center, cumulative index to nursing and allied health literature (CINAHL), Healthcare Literature Information Network, PubPsych, and Social SciSearch databases were searched. The search strategy included terms describing family environment, child characteristics, and language development. Studies were included that (a) assessed distal family variables (such as parental income level, parental education, family size, and parental stress) with child language outcomes, and/or more proximal correlates that directly affect the child (such as family engagement and participation in intervention, parenting style, and more specifically, the quantity and quality of parental linguistic input) on child language; (b) included children implanted before the age of 5 years; (c) measured child language before the age of 21 years with standardized instruments; (d) were published between 1995 and February 2018; and (e) were published as peer-reviewed articles. The methodological quality was assessed with an adaptation of a previously validated checklist. Meta-analyses were conducted assuming a random-effects model.

RESULTS

A total of 22 study populations reported in 27 publications were included. Methodological quality was highly variable. Ten studies had a longitudinal design. Three meta-analyses on the correlations between family variables and child language development could be performed. A strong effect of the quality and quantity of parental linguistic input in the first 4½ years postimplantation on the child's language was found, r = 0.564, p ≤ 0.001, 95% confidence interval (CI) = 0.449 to 0.660, accounting for 31.7% of the variance in child language outcomes. Results demonstrated high homogeneity, Q(3) = 1.823, p = 0.61, I = 0. Higher-level facilitative language techniques, such as parental expansions of the child's utterances or the use of open-ended questions, predicted child language skills. Risk of publication bias was not detected. The results on the impact of family involvement/participation in intervention on child language development were more heterogeneous. The meta-analysis included mainly cross-sectional studies and identified low to moderate benefits, r = 0.380, p ≤ 0.052, 95% CI = -0.004 to 0.667, that almost attained significance level. Socioeconomic status, mainly operationalized by parental level of education, showed a positive correlation with child language development in most studies. The meta-analysis confirmed an overall low and nonsignificant average correlation coefficient, r = 0.117, p = 0.262, 95% CI = -0.087 to 0.312. A limitation of the study was the lack of some potentially relevant variables, such as multilingualism or family screen time.

CONCLUSIONS

These data support the hypothesis that parental linguistic input during the first years after cochlear implantation strongly predicts later child language outcomes. Effects of parental involvement in intervention and parental education are comparatively weaker and more heterogeneous. These findings underscore the need for early-intervention programs for children with cochlear implants focusing on providing support to parents for them to increase their children's exposure to high-quality conversation.

Family Environment in Children With Hearing Aids and Cochlear Implants: Associations With Spoken Language, Psychosocial Functioning, and Cognitive Development

OBJECTIVES

To examine differences in family environment and associations between family environment and key speech, language, and cognitive outcomes in samples of children with normal hearing and deaf and hard-of-hearing (DHH) children who use hearing aids and cochlear implants.

DESIGN

Thirty families of children with normal hearing (n = 10), hearing aids (n = 10), or cochlear implants (n = 10) completed questionnaires evaluating executive function, social skills, and problem behaviors. Children's language and receptive vocabulary were evaluated using standardized measures in the children's homes. In addition, families were administered a standardized in-home questionnaire and observational assessment regarding the home environment.

RESULTS

Family environment overall was similar across hearing level and sensory aid, although some differences were found on parental responsivity and physical environment. The level of supportiveness and enrichment within family relationships accounted for much of the relations between family environment and the psychosocial and neurocognitive development of DHH children. In contrast, the availability of objects and experiences to stimulate learning in the home was related to the development of spoken language.

CONCLUSIONS

Whereas broad characteristics of the family environments of DHH children may not differ from those of hearing children, variability in family functioning is related to DHH children's at-risk speech, language, and cognitive outcomes. Results support the importance of further research to clarify and explain these relations, which might suggest novel methods and targets of family-based interventions to improve developmental outcomes.

Teaching Vocabulary to Improve Print Knowledge in Preschool Children with Hearing Loss

Purpose

The purpose of this article was to examine evidence that (a) published measures may tap different categories of print knowledge and result in disparate findings in the literature, (b) concept vocabulary knowledge in children with hearing loss may exacerbate deficits in conceptual print knowledge, and (c) concept vocabulary can be taught via direct instruction for preschool children with hearing loss.

Method

In Study 1, an item analysis of published print knowledge measures was performed to determine the prevalence of concept vocabulary in test items. Additionally, the performance on a conceptual print knowledge measure was compared for preschool children with and without hearing loss. In Study 2, four preschool children participated in a multiple probe across behaviors treatment design to determine if concept vocabulary could be explicitly taught to children with hearing loss.

Results

Differences emerged in use of concept vocabulary on test items across the measures, which may explain disparate findings that have been reported in this area. Additionally, children with hearing loss performed lower than children with typical hearing on items that contained concept vocabulary but not on items that did not. Finally, we found initial evidence that direct instruction can improve concept vocabulary for children with hearing loss, and it might not be necessary to separately target each concept category.

Conclusion

This series of studies lays groundwork for future research confirming a connection between conceptual print knowledge and conceptual vocabulary knowledge, and offers evidence for intervention that could be used clinically to teach conceptual vocabulary.

Reading Fluency in Young Elementary School Age Deaf and Hard-of-Hearing Children

The Center on Literacy and Deafness examined the language and reading progress of 336 young deaf and hard-of-hearing children in kindergarten, first and second grades on a series of tests of language, reading, and spoken and fingerspelled phonological awareness in the fall and spring of the school year. Children were divided into groups based on their auditory access and classroom communication: a spoken-only group (n = 101), a sign-only group (n = 131), and a bimodal group (n = 104). Previous work reports the overall data (Antia, S., Lederberg, A., Schick, B., Branum-Martin, L., Connor, C. M., & Webb, M. (2020a). Language and reading progress of young DHH children. Journal of Deaf Studies and Deaf Education, (3), 25; Lederberg, A. R., Branum-Martin, L., Webb, M. L., Schick, B., Antia, S., Easterbrooks, S. R., & Connor, C. M. (2019). Modality and interrelations among language, reading, spoken phonological awareness, and fingerspelling. Journal of Deaf Studies and Deaf Education, 24(4), 408-423). This report presents an in-depth look at the reading fluency of the participants measured along multiple dimensions. In general, 43% of the participants were unable to read fluently and an additional 23% were unable to read fluently at grade level. Rate and accuracy, rate of growth, miscue analysis, and self-corrections differed by communication modality. Most notably, children demonstrated limited strategies for self-correction during reading fluency tasks.

Rethinking Emergent Literacy in Children With Hearing Loss

Long-term literacy outcomes for children with hearing loss, particularly those with severe-to-profound deafness who are fitted with cochlear implants (CIs) lag behind those of children with normal hearing (NH). The causes for these long-term deficits are not fully clear, though differences in auditory access between children who use CIs and those with NH may be a partial cause. This paper briefly reviews the emergent literacy model as proposed by Whitehurst and Lonigan (1998). We then examine the development of each of Whitehurst and Lonigan’s identified factors in children who use CIs and how the extant knowledge of language and literacy development in children who use CIs may bear on the emergent literacy model. We then propose to modify the model for children who use CIs based on their unique developmental trajectories, influenced at least in part by their unique auditory access. We conclude with future directions for further development of an evidence-based emergent literacy model for children who use CIs and how this model could be used to inform intervention.

Home Literacy Environment and Emergent Skills in Preschool Children With Hearing Loss

Home literacy practices reported by parents of preschool children with hearing loss were compared to those reported by parents of their peers with typical hearing. Parents completed a questionnaire from Boudreau, D. (2005. Use of a parent questionnaire in emergent and early literacy assessment of preschool children. Language, Speech, and Hearing Services in Schools, 36, 33-47. doi:10.1044/0161-1461(2005/004)) assessing home literacy practices across areas such as parent facilitation of literacy and time spent reading per week. As part of a larger study, children completed language and emergent literacy assessments. Parents of both groups reported similar amounts of time spent reading to their children and scored similarly on report of parent facilitation of literacy, even though children with hearing loss scored lower on measures of emergent literacy. However, parents of children with typical hearing reported that their children had higher engagement and interest in books than children with hearing loss. Additionally, only child engagement with books was correlated with emergent literacy skills and only for children with hearing loss. The results suggest that parent facilitation of literacy alone is not correlated with emergent literacy scores; children must take an active role in their reading development. Children with hearing loss must be active participants during shared book reading. It is therefore essential to develop ways to actively engage children with hearing loss during reading activities.

Effects of Age at Cochlear Implantation on Learning and Cognition: A Critical Assessment

Purpose Age at cochlear implantation frequently is assumed to be a key predictor of pediatric implantation benefits, but outcomes related to learning and cognition appear inconsistent. This critical assessment examines relevant literature in an effort to evaluate the impact of age at implantation in those domains for individuals who received their devices as children. Method We examined 44 peer-reviewed articles from 2003 to 2018 considering age at implantation and conducted statistical analyses regarding its impact on several domains, including literacy, academic achievement, memory, and theory of mind. Results Across 167 assessments in various experiments and conditions, only 21% of the analyses related to age at implantation yielded evidence in favor of earlier implantation, providing greater benefits to academic achievement, learning, or cognition compared to implantation later in childhood. Among studies that considered cognitive processing (e.g., executive function, memory, visual-spatial functioning), over twice as many analyses indicated significant benefits of earlier implantation when it was considered as a discrete rather than a continuous variable. Conclusion Findings raise methodological, practical, and theoretical questions concerning how "early" is defined in studies concerning early cochlear implantation, the impact of confounding factors, and the use of nonstandard outcome measures. The present results and convergent findings from other studies are discussed in terms of the larger range of variables that need to be considered in evaluating the benefits of cochlear implantation and question the utility of considering age at implantation as a "gold standard" with regard to evaluating long-term outcomes of the procedure as a medical treatment/intervention for hearing loss. Supplemental Material https://doi.org/10.23641/asha.8323625.

Relations Between Teacher Talk Characteristics and Child Language in Spoken-Language Deaf and Hard-of-Hearing Classrooms

PURPOSE

The aim of this study was to examine relations between teachers' conversational techniques and language gains made by their deaf and hard-of-hearing students. Specifically, we considered teachers' reformulations of child utterances, language elicitations, explicit vocabulary and syntax instruction, and wait time.

METHOD

This was an observational, longitudinal study that examined the characteristics of teacher talk in 25 kindergarten through second-grade classrooms of 68 deaf and hard-of-hearing children who used spoken English. Standardized assessments provided measures of child vocabulary and morphosyntax in the fall and spring of a school year. Characteristics of teacher talk were coded from classroom video recordings during the winter of that year.

RESULTS

Hierarchical linear modeling indicated that reformulating child statements and explicitly teaching vocabulary were significant predictors of child vocabulary gains across a school year. Explicitly teaching vocabulary also significantly predicted gains in morphosyntax abilities. There were wide individual differences in the teachers' use of these conversational techniques.

CONCLUSION

Reformulation and explicit vocabulary instruction may be areas where training can help teachers improve, and improvements in the teachers' talk may benefit their students.

It Takes Two to Read: Interactive Reading with Young Deaf and Hard-of-Hearing Children

Interactive storybook reading is an important activity to enhance the emergent literacy skills of young deaf and hard-of-hearing (DHH) children. Parents have a crucial role to play in promoting their children's literacy development. However, parents often do not read in an interactive way; therefore guidance is recommended in applying these interactive reading strategies. In the present study we examined how parent reading behavior was affected by implementing an interactive reading training program for parents of young DHH children. Parents of 18 DHH toddlers in the Netherlands participated in a series of group training sessions and their interactive reading behavior was compared to that of 10 parents who did not participate. The results showed that parents' interactive reading behavior tended to increase after they participated in the interactive reading program. After the program, they applied the interactive reading strategies more often than parents who had not participated in the program. The findings suggest that interactive reading programs should be incorporated into early intervention programs for DHH children.

The Effects of Parent Training on Vocabulary Scores of Young Children With Hearing Loss

PURPOSE

The purpose of this study is to evaluate the effects of short-term parent training on maternal use of language stimulation strategies and vocabulary scores in children with hearing loss.

METHOD

Six mother-child dyads participated in the multiple-baseline study. During baseline and maintenance, children engaged in a business-as-usual model of clinician-only therapy. During intervention, mothers and children participated in parent training focused on transparent labeling and linguistic mapping strategies. Parent strategy use was measured via weekly play-based probe assessments. Child vocabulary growth was measured via parent report.

RESULTS

A relation between parent training and use of transparent labeling was established for all mothers, and a relation between parent training and use of linguistic mapping was established for 3 of 6 mothers. Child vocabulary growth rate increased from baseline to intervention in 4 of 6 children.

CONCLUSIONS

Short-term parent training can change parent behavior. However, parents may not maintain these skills without support. Further research is needed to characterize the extent to which short-term training can make long-term changes in parent and child outcomes.

Communication dynamics between mothers and their children with cochlear implants: Effects of maternal support for language production

This study examined (a) the functions and modalities of maternal and child communication during interaction between mothers and children with cochlear implants (CIs), comparing them with mothers and normally hearing (NH) children, and (b) the effectiveness of maternal support strategies in eliciting adequate answers in children with CI. Twenty preschoolers with CIs (M = 40 months) and 40 NH children - 20 matched by chronological age (CANH, M = 40 months) and 20 matched by hearing age (HANH, M = 25 months) - were videotaped during shared book reading and toy play with their mothers. Child and maternal utterances were coded for communicative functions and modalities (vocal, gestural, bimodal), including gesture types; maternal repairs were examined for type of support provided, and child answers for adequacy. Mothers in the CI group and in the CANH group displayed higher proportions of Informative Repairs than mothers of HANH children. However, unlike the mothers of NH children, mothers of children with CIs used bimodal utterances significantly more than vocal utterances. Sequential analysis revealed that maternal Informative Repairs elicited the production of Adequate Answers in both children with CIs and CANH. Interestingly, in the CI group this association was found only when Informative Repairs were accompanied by gestures. These findings offer suggestions for intervention programs focused on parent-child conversation.

Literacy Outcomes in Deaf Students with Cochlear Implants: Current State of the Knowledge

The purpose of this paper is to examine the available peer-reviewed research regarding literacy achievement in deaf children with cochlear implants. A related goal is to identify gaps in the empirical literature and suggest directions for future research. Included in this review are studies that exclusively report reading and writing outcomes for groups of students. A total of 21 studies were identified, representing those published over approximately a 20-year time period (1997-2016) and collectively reporting the literacy outcomes for over 1,000 cochlear implant users. Overall findings of the studies of reading comprehension suggest that the majority of participants achieved scores in the average range, although a wide-range of variability was reported. Only 3 studies of writing were available for review, with 2 reporting lower achievement in this area as compared to reading. Factors impacting outcomes achieved such as age at implantation, presence of additional disabilities, consistency of device use, and communication modality are explored and summarized.

Reliability of the Language ENvironment Analysis system (LENA™) in European French

In this study, we examined the accuracy of the Language ENvironment Analysis (LENA) system in European French. LENA is a digital recording device with software that facilitates the collection and analysis of audio recordings from young children, providing automated measures of the speech overheard and produced by the child. Eighteen native French-speaking children, who were divided into six age groups ranging from 3 to 48 months old, were recorded about 10-16 h per day, three days a week. A total of 324 samples (six 10-min chunks of recordings) were selected and then transcribed according to the CHAT format. Simple and mixed linear models between the LENA and human adult word count (AWC) and child vocalization count (CVC) estimates were performed, to determine to what extent the automatic and the human methods agreed. Both the AWC and CVC estimates were very reliable (r = .64 and .71, respectively) for the 324 samples. When controlling the random factors of participants and recordings, 1 h was sufficient to obtain a reliable sample. It was, however, found that two age groups (7-12 months and 13-18 months) had a significant effect on the AWC data and that the second day of recording had a significant effect on the CVC data. When noise-related factors were added to the model, only a significant effect of signal-to-noise ratio was found on the AWC data. All of these findings and their clinical implications are discussed, providing strong support for the reliability of LENA in French.

Auditory Environment Across the Life Span of Cochlear Implant Users: Insights From Data Logging

PURPOSE

We describe the natural auditory environment of people with cochlear implants (CIs), how it changes across the life span, and how it varies between individuals.

METHOD

We performed a retrospective cross-sectional analysis of Cochlear Nucleus 6 CI sound-processor data logs. The logs were obtained from 1,501 people with CIs (ages 0-96 years). They covered over 2.4 million hr of implant use and indicated how much time the CI users had spent in various acoustical environments. We investigated exposure to spoken language, noise, music, and quiet, and analyzed variation between age groups, users, and countries.

RESULTS

CI users spent a substantial part of their daily life in noisy environments. As a consequence, most speech was presented in background noise. We found significant differences between age groups for all auditory scenes. Yet even within the same age group and country, variability between individuals was substantial.

CONCLUSIONS

Regardless of their age, people with CIs face challenging acoustical environments in their daily life. Our results underline the importance of supporting them with assistive listening technology. Moreover, we found large differences between individuals' auditory diets that might contribute to differences in rehabilitation outcomes. Their causes and effects should be investigated further.

Interactive Reading with Young Deaf and Hard-of-Hearing Children in eBooks Versus Print Books

Interactive storybook reading is effective in enhancing deaf and hard-of-hearing (DHH) children's emergent literacy skills. The current digital era gives parents more opportunities to read books with their child. From an early age on, interaction between parent and child during literacy activities is very important for the development of emergent literacy skills. The purpose of the present study was to explore the opportunities of eBooks on a tablet for interactive reading with young DHH children. Parent and child interactive behavior in reading print books was compared to eBooks in 18 parents and their 1- to 3-year-old DHH child. All parents followed an interactive reading program after which their interactive reading behaviors were observed while reading print books and eBooks with their child. Results mainly showed similar interactive reading behaviors in parents and children when reading print books or eBooks, except for a lower occurrence of pointing to pictures/objects in the parent behavior when reading the eBooks. These results give parents and professionals even more opportunities for interactive storybook reading with DHH children, and thus more opportunities to enhance their language and literacy skills. Tablets can be easily taken with you making eBooks accessible for interactive reading wherever you are.

What Is the International Classification of Functioning, Disability and Health and Why Is It Relevant to Audiology?

The World Health Organization's International Classification of Functioning, Disability and Health (ICF) is widely used in disability and health sectors as a framework to describe the far-reaching effects of a range of health conditions on individuals. This biopsychosocial framework can be used to describe the experience of an individual in the components of body functions, body structures, and activities and participation, and it considers the influence of contextual factors (environmental and personal) on these components. Application of the ICF in audiology allows the use of a common language between health care professionals in both clinical and research settings. Furthermore, the ICF is promoted as a means of facilitating patient-centered care. In this article, the relevance and application of the ICF to audiology is described, along with clinical examples of its application in the assessment and management of children and adults with hearing loss. Importantly, the skills necessary for clinicians to apply the ICF effectively are discussed.

Symbolic Play and Novel Noun Learning in Deaf and Hearing Children: Longitudinal Effects of Access to Sound on Early Precursors of Language

In the largest, longitudinal study of young, deaf children before and three years after cochlear implantation, we compared symbolic play and novel noun learning to age-matched hearing peers. Participants were 180 children from six cochlear implant centers and 96 hearing children. Symbolic play was measured during five minutes of videotaped, structured solitary play. Play was coded as "symbolic" if the child used substitution (e.g., a wooden block as a bed). Novel noun learning was measured in 10 trials using a novel object and a distractor. Cochlear implant vs. normal hearing children were delayed in their use of symbolic play, however, those implanted before vs. after age two performed significantly better. Children with cochlear implants were also delayed in novel noun learning (median delay 1.54 years), with minimal evidence of catch-up growth. Quality of parent-child interactions was positively related to performance on the novel noun learning, but not symbolic play task. Early implantation was beneficial for both achievement of symbolic play and novel noun learning. Further, maternal sensitivity and linguistic stimulation by parents positively affected noun learning skills, although children with cochlear implants still lagged in comparison to hearing peers.

Schooling Relates to Mental Health Problems in Adolescents with Cochlear Implants-Mediation by Hearing and Family Variables

Aim of this multicenter study was to investigate whether schooling relates to mental health problems of adolescents with cochlear implants (CI) and how this relationship is mediated by hearing and family variables. One hundred and forty secondary school students with CI (mean age = 14.7 years, SD = 1.5), their hearing parents and teachers completed the Strengths and Difficulties Questionnaire (SDQ). Additional audiological tests (speech comprehension tests in quiet and noise) were performed. Students of special schools for hearing impaired persons (SSHIs) showed significantly more conduct problems (p < 0.05) and a significantly higher total difficulty score (TDS) (p < 0.05) compared to students of mainstream schools. Mental health problems did not differ between SSHI students with sign language education and SSHI students with oral education. Late implanted students and those with indication for additional handicaps were equally distributed among mainstream schools and SSHIs. However, students in SSHIs were more restricted to understand speech in noise, had a lower social background and were more likely to come from single-parent families. These factors were found to be partial mediators of the differences in mental health problems between the two school types. However, no variable could explain comprehensively, why students of SSHIs have more mental health problems than mainstream pupils.

Factors influencing speech and language outcomes of children with early identified severe/profound hearing loss: Clinician-identified facilitators and barriers

PURPOSE

Early identification of severe/profound childhood hearing loss (HL) gives these children access to hearing devices and early intervention to facilitate improved speech and language outcomes. Predicting which infants will go on to achieve such outcomes remains difficult. This study describes clinician identified malleable and non-malleable factors that may influence speech and language outcomes for children with severe/profound HL.

METHOD

Semi-structured interviews were conducted with six experienced auditory verbal clinicians. A collective case study design was implemented. The interviews were transcribed and coded into themes using constant comparative analysis.

RESULT

Clinicians identified that, for children with severe/profound HL, early identification, early amplification and commencing auditory-verbal intervention under 6 months of age may facilitate child progress. Possible barriers were living in rural/remote areas, the clinicians' lack of experience and confidence in providing intervention for infants under age 6-months and belonging to a family with a culturally and linguistically diverse (CALD) background.

CONCLUSION

The results indicate that multiple factors need to be considered by clinicians working with children with HL and their families to determine how each child functions within their own environment and personal contexts, consistent with the International Classification of Functioning, Disability and Health (ICF) framework. Such an approach is likely to empower clinicians to carefully balance potential barriers to, and facilitators of, optimal speech and language outcomes for all children with HL.

Development of joint engagement in young deaf and hearing children: effects of chronological age and language skills

PURPOSE

To evaluate joint engagement (JE) in age-matched children with and without hearing and its relationship to oral language skills.

METHOD

Participants were 180 children with severe-to-profound hearing loss prior to cochlear implant surgery, and 96 age-matched children with normal hearing; all parents were hearing. JE was evaluated in a 10-minute videotaped free play task with parents. Engagement states ranged from the lowest (unengaged) to the highest level (symbol-infused coordinated). Standardized language measures were administered.

RESULTS

Multivariate analyses were conducted between the groups, stratified by chronological and language age. Children who were deaf (Deaf) spent less time in total symbol-infused JE than children with normal hearing (NH) across all ages. The majority of the Deaf group (83%) fell in the lowest language age group, in comparison to 35% of the NH group, and spent significantly less time in symbol-infused JE than hearing children. These delays were also observed in the Deaf group, who fell into the 18-36 month language age. No children in the Deaf group had achieved a language age of > 36 months.

CONCLUSIONS

Young children with and without hearing had different developmental trajectories of JE, which were related to oral language skills.

Study of phonological awareness of preschool and school aged children with cochlear implant and normal hearing

Background and Objectives

The primary purpose of this study was to assess whether very early access to speech sounds provided by the cochlear implant enables children to develop age-appropriate phonological awareness abilities in their preschool and school years. A secondary purpose of this study was to examine whether children who had cochlear implantation before 18 months of age will develop better skills in phonological awareness than children who had cochlear implants in 18-36 months of age. A third purpose of this study was to examine whether some factors like the child's age or sex would have any effects on developing of age-appropriate phonological awareness abilities.

Subjects and Methods

48 children with 70 to 95 months of age who had been utilizing their cochlear implant(s) before 36 months of age (CI group) and 30 normal hearing peers (NH group) were enrolled in this study.

Results

Child's age had a significant effect on phonological awareness, but sex had absolutely no effect in each group. Children in the cochlear implanted group were outperformed by their normal hearing peers in the area of phonological awareness, especially in phonemic awareness. The age of implantation was another significant variable.

Conclusions

Although children with a younger age at implantation got better scores in phonological awareness test, they were outperformed by their normal hearing peers in this area.

Parental Support for Language Development During Joint Book Reading for Young Children With Hearing Loss

Parent and child joint book reading (JBR) characteristics and parent facilitative language techniques (FLTs) were investigated in two groups of parents and their young children; children with normal hearing (NH; n = 60) and children with hearing loss (HL; n = 45). Parent-child dyads were videotaped during JBR interactions, and parent and child behaviors were coded for specific JBR behaviors using a scale developed for this study. Children's oral language skills were assessed using the Preschool Language Scale-4 (PLS-4). Parents of children with HL scored higher on two of the four subscales of JBR: Literacy Strategies and Teacher Techniques. Parents of children with NH utilized higher level FLTs with their children who had higher language skills. Higher level FLTs were positively related to children's oral language abilities. Implications are discussed for professionals who work with families of very young children with HL.

Inferences and metaphoric comprehension in unilaterally implanted children with adequate formal oral language performance

OBJECTIVES

To assess skills in inferences during conversations and in metaphors comprehension of unilaterally cochlear implanted children with adequate abilities at the formal language tests, comparing them with well-matched hearing peers; to verify the influence of age of implantation on overall skills.

METHODS

The study was designed as a matched case-control study. 31 deaf children, unilateral cochlear implant users, with normal linguistic competence at formal language tests were compared with 31 normal hearing matched peers. Inferences and metaphor comprehension skills were assessed through the Implicit Meaning Comprehension, Situations and Metaphors subtests of the Italian Standardized Battery of "Pragmatic Language Skills MEDEA". Differences between patient and control groups were tested by the Mann-Whitney U test. Correlations between age at implantation and time of implant use with each subtest were investigated by the Spearman rank correlation coefficient.

RESULTS

No significant differences between the two groups were found in inferencing skills (p=0.24 and p=0.011 respectively for Situations and Implicit Meaning Comprehension). Regarding figurative language, unilaterally cochlear implanted children performed significantly below their normal hearing peers in Verbal Metaphor comprehension (p=0.001). Performances were related to age at implantation, but not with time of implant use.

CONCLUSIONS

Unilaterally cochlear implanted children with normal language level showed responses similar to NH children in discourse inferences, but not in figurative language comprehension. Metaphors still remains a challenge for unilateral implant users and above all when they have not any reference, as demonstrated by the significant difference in verbal rather than figurative metaphors comprehension. Older age at implantation was related to worse performance for all items. These aspects, until now less investigated, had to receive more attention to deeply understand specific mechanisms involved and possible effects of different levels of figurative language complexity (presence or absence of contextual input, degree of transparency and syntactic frozenness). New insight is needed to orient programs in early intervention settings in considering and adequately responding to all these complex communicative need of children with hearing loss.

Principles and guidelines for early intervention after confirmation that a child is deaf or hard of hearing

This document is a supplement to the year 2007 position statement of the Joint Committee on Infant Hearing and provides comprehensive guidelines for establishing strong early intervention (EI) systems with appropriate expertise to meet the needs of children who are deaf or hard of hearing (D/HH). Optimal outcomes can only be achieved when there is high quality to the universal newborn hearing screening programs, the audiologic diagnostic process of confirmation that a child is D/HH and fitting of amplification, and the provision of appropriate, individualized, targeted, and high-quality EI services. There are 12 best practice guidelines for EI programs that include the provision of timely referral to EI services with providers who have knowledge and skills in early childhood deafness and hearing loss, infusion within the system of partnerships with parents as well as professionals who are D/HH, longitudinal developmental assessments for monitoring the child's development, data management systems that include developmental outcomes, a process to monitor the fidelity of the intervention, and appropriate services for children with additional disabilities, those from non-English speaking families, and those from special populations, including unilateral hearing loss and auditory neuropathy/dyssynchrony.

Developmental effects of family environment on outcomes in pediatric cochlear implant recipients

OBJECTIVE

To examine and compare the family environment of preschool- and school-age children with cochlear implants and assess its influence on children's executive function and spoken language skills.

STUDY DESIGN

Retrospective between-subjects design.

SETTING

Outpatient research laboratory.

PATIENTS

Prelingually deaf children with cochlear implants and no additional disabilities and their families.

INTERVENTION(S)

Cochlear implantation and speech-language therapy.

MAIN OUTCOME MEASURES

Parents completed the Family Environment Scale and the Behavior Rating Inventory of Executive Function (or the preschool version). Children were tested using the Peabody Picture Vocabulary Test-4 and either the Preschool Language Scales-4 or the Clinical Evaluation of Language Fundamentals-4.

RESULTS

The family environments of children with cochlear implants differed from normative data obtained from hearing children, but average scores were within 1 standard deviation of norms on all subscales. Families of school-age children reported higher levels of control than those of preschool-age children. Preschool-age children had fewer problems with emotional control when families reported higher levels of support and lower levels of conflict. School-age children had fewer problems with inhibition but more problems with shifting of attention when families reported lower levels of conflict. School-age children's receptive vocabularies were enhanced by families with lower levels of control and higher levels of organization.

CONCLUSION

Family environment and its relation to language skills and executive function development differed across the age groups in this sample of children with cochlear implants. Because family dynamics is one developmental/environmental factor that can be altered with therapy and education, the present results have important clinical implications for family-based interventions for deaf children with cochlear implants.

Language and behavioral outcomes in children with developmental disabilities using cochlear implants

OBJECTIVE

Over the past decade, the number of deaf children with developmental disabilities receiving cochlear implants has increased dramatically. However, little is known about the developmental outcomes of these children post-implantation. The current study evaluated oral language and behavioral outcomes over 3 years after implantation in a sample of typically developing deaf children and children with developmental disabilities.

STUDY DESIGN

A three year longitudinal study of the effects of cochlear implantation on language and behavioral outcomes in children with and without additional disabilities.

SETTING

Six cochlear implant centers in the United States.

PATIENTS

The study cohort consisted of 188 deaf children. Eighty-five percent of the sample (n = 157) had a single diagnosis of severe to profound hearing loss and 15% (n = 31) had an additional disability.

MAIN OUTCOME MEASURES

Oral language was assessed using the Reynell Developmental Language Scales, and behavioral outcomes were assessed using the Child Behavior Checklist.

RESULTS

Results using multilevel modeling indicated that deaf children with and without additional disabilities improved significantly in oral language skills post-implantation. However, children with additional disabilities made slower progress. In terms of specific diagnoses, children with developmental disorders, such as autism, made the slowest progress over time. In addition, behavior problems increased significantly in this group, whereas behavior problems decreased over 3 years in the typically developing deaf sample.

CONCLUSION

Overall, given the improvements in expressive and receptive language skills documented over 3 years, these findings support the use of cochlear implants for deaf children with developmental disabilities.

Identification of effective strategies to promote language in deaf children with cochlear implants

Parental involvement and communication are essential for language development in young children. However, hearing parents of deaf children face challenges in providing language input to their children. This study utilized the largest national sample of deaf children receiving cochlear implants, with the aim of identifying effective facilitative language techniques. Ninety-three deaf children (≤ 2 years) were assessed at 6 implant centers prior to and for 3 years following implantation. All parent-child interactions were videotaped, transcribed, and coded at each assessment. Analyses using bivariate latent difference score modeling indicated that higher versus lower level strategies predicted growth in expressive language and word types predicted growth in receptive language over time. These effective, higher level strategies could be used in early intervention programs.

Growing up with a cochlear implant: education, vocation, and affiliation

The long-term educational/vocational, affiliation, and quality-of-life outcomes of the first and second cohorts of children with bilateral, profound hearing loss who received cochlear implants under a large National Institutes of Health-funded study was investigated in 41 of 61 eligible participants. Educational and vocational outcomes were collected from user survey data. Affiliation and quality-of-life data were collected from the Satisfaction-with-Life scale and the Deaf Identity Scale. Qualitative results indicated that compared with their hearing, adult-age peers, this group obtained high educational achievement, and they reported a very high satisfaction of life. With respect to forming an identity in these first 2 cohorts of cochlear implant users, we found that most of the individuals endorsed a dual identity, which indicates they feel just as comfortable with Deaf individuals as they do with hearing individuals. Quantitative results revealed a significant relationship between ability to hear and ability to speak, in addition to consistency of device use. Additional relationships were found between mother's and the individual's educational statuses, hearing scores, and communication system used. Younger individuals scored higher on satisfaction-with-life measures, and they also tended to endorse a dual identity more often. Taken together, these findings diminish concerns that profoundly deaf individuals growing up with cochlear implants will become culturally bereft and unable to function in the hearing world.

Quantity of parental language in the home environments of hard-of-hearing 2-year-olds

Automated analyses of full-day recordings were used to determine whether young children who are hard-of-hearing (HH) received similar levels of exposure to adult words and conversational interactions as age-matched peers with normal-hearing (NH). Differences in adult input between children in this study and in a normative database were considered. Finally, factors were examined that may have contributed to individual differences in the input characteristics of families. Results indicated that the NH and HH groups were exposed to similar numbers of adult words and conversational turns. However, both the NH and HH groups were exposed to more adult words and engaged in more conversational turns than the NH children in the normative sample. Considering only the HH group, both quantity of adult words and conversational exchanges were correlated with children's auditory characteristics. Children's receptive language ability was correlated with conversational exchanges but not with adult word counts.

Contribution of family environment to pediatric cochlear implant users' speech and language outcomes: some preliminary findings

PURPOSE

To evaluate the family environments of children with cochlear implants and to examine relationships between family environment and postimplant language development and executive function.

METHOD

Forty-five families of children with cochlear implants completed a self-report family environment questionnaire (Family Environment Scale--Fourth Edition; Moos & Moos, 2009) and an inventory of executive function (Behavior Rating Inventory of Executive Function [Gioia, Isquith, Guy, & Kenworthy, 2000] or Behavior Rating Inventory of Executive Function--Preschool Version [Gioia, Espy, & Isquith, 2003]). The authors also evaluated children's receptive vocabulary (Peabody Picture Vocabulary Test--Fourth Edition; Dunn & Dunn, 2007) and global language skills (Preschool Language Scale--Fourth Edition [Zimmerman, Steiner, & Pond, 2002] and Clinical Evaluation of Language Fundamentals--Fourth Edition [Semel, Wiig, & Secord, 2003]).

RESULTS

The family environments of children with cochlear implants differed from those of normal-hearing children but not in clinically significant ways. Language development and executive function were found to be atypical but not uncharacteristic of this clinical population. Families with higher levels of self-reported control had children with smaller vocabularies. Families reporting a higher emphasis on achievement had children with fewer executive function and working memory problems. Finally, families reporting a higher emphasis on organization had children with fewer problems related to inhibition.

CONCLUSION

Some of the variability in cochlear implantation outcomes that have protracted periods of development is related to family environment. Because family environment can be modified and enhanced by therapy or education, these preliminary findings hold promise for future work in helping families to create robust language-learning environments that can maximize their child's potential with a cochlear implant.

Phonological awareness and print knowledge of preschool children with cochlear implants

PURPOSE

To determine whether preschool-age children with cochlear implants have age-appropriate phonological awareness and print knowledge and to examine the relationships of these skills with related speech and language abilities.

METHOD

The sample comprised 24 children with cochlear implants (CIs) and 23 peers with normal hearing (NH), ages 36 to 60 months. Children's print knowledge, phonological awareness, language, speech production, and speech perception abilities were assessed.

RESULTS

For phonological awareness, the CI group's mean score fell within one standard deviation of the Test of Preschool Early Literacy's (Lonigan, Wagner, Torgesen, & Rashotte, 2007) normative sample mean but was more than one standard deviation below the NH group mean. The CI group's performance did not differ significantly from that of the NH group for print knowledge. For the CI group, phonological awareness and print knowledge were significantly correlated with language, speech production, and speech perception. Together these predictor variables accounted for 34% of variance in the CI group's phonological awareness but no significant variance in their print knowledge.

CONCLUSIONS

Children with CIs have the potential to develop age-appropriate early literacy skills by preschool age but are likely to lag behind their NH peers in phonological awareness. Intervention programs serving these children should target these skills with instruction and by facilitating speech and language development.

The Importance of the Home Literacy Environment for Developing Literacy Skills in Young Children Who Are Deaf or Hard of Hearing

Four-year-old Olivia, who is deaf and has used a cochlear implant for 3 years, and her mother, Laura, enjoy looking at storybooks together at home. During storybook reading, Laura notices that Olivia tries to imitate some words that she reads to her yet does not seem to understand many words or story events. Laura is unsure whether to stop the storybook interaction and encourage Olivia’s attempts at word imitation and directly teach her the new vocabulary or continue reading the story for pleasure. Olivia’s preschool teacher, Ms. Lynn, also notices that Olivia displays a keen interest in storybook reading but is not able to answer or ask simple questions about the story. What can Laura and Ms. Lynn do collaboratively to support Olivia’s emerging language and literacy skills to better prepare Olivia for her upcoming transition into kindergarten?

Parenting Stress among Parents of Deaf and Hearing Children: Associations with Language Delays and Behavior Problems

OBJECTIVE: This study evaluates predictors of both general and context-specific parenting stress in a cross-sectional sample of hearing parents of young deaf and hearing children. DESIGN: Participants were 181 children who were deaf and 92 children with normal hearing. Perceived parenting stress was measured using both general and context-specific measures. Predictors of parenting stress included parent-reported and observed child behavior problems and language delays. RESULTS: After controlling for maternal education and family income, parents of deaf children reported more context-specific but not general parenting stress than parents of hearing children. Both parent-reported and observed behavior problems were higher in the deaf group compared to the hearing group. Children's hearing status related to child behavior problems by way of oral language delays. Furthermore, hearing status related to parenting stress by way of language delays and child behavior difficulties. CONCLUSIONS: Context-specific measures of parenting stress reflect unique challenges of this population. Both language delays and child behavior problems are associated with increased parenting stress. Identification of specific stressors related to parenting a deaf child helps to inform the development of early interventions.