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

Assessing parent-child interaction with deaf and hard of hearing infants aged 0-3 years: An international multi-professional e-Delphi

INTRODUCTION

Most deaf babies are born to hearing families who do not yet have the skills to communicate effectively with their child. Adaptations to communication are important because the quality of parent-child interaction (PCI) predicts how a deaf child develops language. Teachers of Deaf children and Speech and Language Therapists support families with communication in the home. Currently, there are no assessments that appraise how a parent interacts with their deaf baby. Previous research has identified which parent behaviours and approaches are used in PCI assessments in research and practice. The current paper forms consensus on the core content and best practices of a new PCI tool for deaf children aged 0-3 years.

METHODS

An international sample of expert academics and practitioners (n = 83) were recruited to take part in a two-round modified electronic Delphi study. Participants were presented with 69 statements focusing on (i) which parent behaviours were important in assessment (ii) the methods to be used in PCI assessment. Participants rated the extent to which they agreed or disagreed with each statement on a five-point Likert scale and gave comments to support their response. Consensus was defined as >80% of participants rating the statement as a (4) 'highly important' or a (5) 'essential'. If consensus was not reached, participant comments were used to generate new statements which were rated in the second round. This project involved a patient and public involvement (PPI) group of hearing and deaf parents and professionals to design and guide the study.

RESULTS

Consensus was achieved on 52 statements and ranged from 80-99%. A further six statements were additionally included. Within the 58 statements included, 36 were parent behaviours which centred on the parent's observation of, and response to, their child's behaviour and/or language. The remaining 22 statements focused on methods used in the assessment such as parents having their PCI filmed, parents having the opportunity to review the video and assess themselves alongside a professional, and parents being involved in subsequent goal setting.

CONCLUSIONS

This e-Delphi presented the parent behaviours and methods of assessment to be included in a new PCI tool for deaf children. Future co-production work and acceptability and feasibility testing are discussed.

Narrative Intervention for Preschoolers Who Are Deaf and Hard of Hearing Using Listening and Spoken Language: A Pilot Study

PURPOSE

This pilot study aimed to examine the effects of a caregiver-supported, narrative-based intervention program on the story retelling skills of a group of preschoolers who are deaf and hard of hearing (D/HH) using listening and spoken language (LSL).

METHOD

A concurrent multiple baseline design across participants was used to determine the effect of a narrative intervention on the story retelling skills of three preschool-age participants who demonstrated complex language delays. Their primary caregivers also functioned as participants. The 6-week narrative intervention program was implemented using a caregiver coaching model during individual therapy sessions. The dependent variable probes were administered twice per week across phases to assess the preschool participants' story retelling skills, including story grammar, complexity, and completeness. Social validity was also evaluated using a caregiver questionnaire.

RESULTS

A functional relation was demonstrated between the intervention and story retelling across all three preschool participants with notable increases in the inclusion of story grammar elements and episodic completeness. All three participants maintained scores above baseline levels on dependent variable probes across the 6-week maintenance period. Social validity was strong according to the results of a caregiver questionnaire completed at the conclusion of the intervention.

CONCLUSION

These findings offer preliminary support for the use of a caregiver-supported, narrative-based intervention program to improve storytelling and retelling skills in preschoolers who are D/HH using LSL.

Australian families of deaf and hard of hearing children: Are they using sign?

BACKGROUND

Deaf and hard of hearing (DHH) children may experience communication delays, irrespective of early intervention and technology. Australian Sign Language (Auslan) is one approach in early intervention to address language delays. Current prevalence of Auslan use among Australian families with DHH children is unknown.

AIMS

The first aim was to determine the proportion of families enrolled in an Australian statewide hearing loss databank who use Auslan with their DHH child. The second aim was to explore the relationships between indicators of child hearing loss (bilateral or unilateral hearing loss, degree of hearing loss, and device use: hearing aids and cochlear implants), family factors (maternal education, attendance at early intervention, family history of deafness, and socio-economic disadvantage) and the family's reported use of Auslan.

METHODS

We analysed the enrolment data from 997 families who participated in an Australian statewide hearing loss databank between 2012 and 2021. We described the proportion of families who used Auslan with their DHH child at home. The association between indicators of child hearing loss and family factors, and the parental reports of communication approach were examined using correlation analyses.

RESULTS

Eighty-seven of 997 parents (8.7%) reported using Auslan with their DHH child. Of these, 26 (2.6%) used Auslan as their primary language. The use of Auslan at home was associated with the following indicators of child hearing loss: bilateral hearing loss, profound compared to mild hearing loss, and cochlear implant and hearing aid use compared to no device use. The family factors associated with the use of Auslan were: referral or attendance at early intervention compared to those who did not attend, and a family history of deafness compared to those with none. No association was found between maternal education and socio-economic disadvantage and the use of Auslan.

CONCLUSION

This Australian study found a low proportion (8.7%) of families with a DHH child who reported using Auslan. Seven child hearing loss and family factors were considered, and five were significantly associated with using Auslan at home. Children with a greater degree of hearing loss, attendance at early intervention and family history of deafness tended to use Auslan.

"It doesn't matter if we're the most amazing professionals in the world…" A qualitative study of professionals' perspectives on parent-child interaction assessment with deaf infants

Introduction

Parent child interaction (PCI) is positively associated with deaf children's language development. However, there are no known, deaf-specific tools to observe how a parent interacts with their deaf child aged 0-3 years. Without a framework for professionals to use with families, it is unknown how professionals assess PCI, what they assess, why they assess, and how the assessment results relate to case management.

Methods

Eighteen hearing and deaf professionals, who work with deaf and hard of hearing infants aged 0-3 years and their families, attended online focus groups. The aim of the study was to gain insight into the professional assessment of PCI. Data were analyzed using thematic analysis.

Findings

Six themes were generated from the dataset. Professionals discussed how central parents were in the support offered to families in the home, the importance of knowing and understanding the individual family, and accounting for and supporting parental wellbeing. Descriptions on how to administer a best practice PCI assessment included which parent behaviors to assess and how to make adaptations for different populations. Professionals shared how the assessment and review process could be used to inform and upskill parents through video reflection and goal setting.

Discussion

This study provides insight into the mechanisms and motivations for professionals assessing the interactive behaviors of parents who have deaf children aged 0-3. Professionals acknowledged that family life is multi-faceted, and that support is most meaningful to families when professionals worked with these differences and incorporated them into assessment, goal setting, and intervention plans.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Support Principles

This article is the sixth in a series of eight articles that comprise a special issue on Family-Centered Early Intervention (FCEI) for children who are deaf or hard of hearing (DHH) and their families, or FCEI-DHH. The Support Principles article is the second of three articles that describe the 10 Principles of FCEI-DHH, preceded by the Foundation Principles, and followed by the Structure Principles, all in this special issue. The Support Principles are composed of four Principles (Principles 3, 4, 5, and 6) that highlight (a) the importance of a variety of supports for families raising children who are DHH; (b) the need to attend to and ensure the well-being of all children who are DHH; (c) the necessity of building the language and communication abilities of children who are DHH and their family members; and (d) the importance of considering the family's strengths, needs, and values in decision-making.

Linguistic Intervention Strategies Speech-Language Pathologists Use With Children Using Cochlear Implants

The aim of this study was to explore the strategies that speech-language pathologists (SLPs) use during their linguistic interventions on children with cochlear implants (CIs). The sample comprised 7 SLPs in interactions with 62 children, 31 with CIs and 31 with typical hearing (TH), from 5 to 7 years of age. Two linguistic activities were used: conversation and naming. With children with CIs, the SLPs used 3.8 times more adaptation strategies and 5 times more educational strategies in the conversation activity, and 1.4 times more educational strategies in the naming activity than with children with TH. Communication strategies were significantly more frequent in the conversation activity than in the naming activity while educational strategies were more frequent in the naming activity than in the conversation activity. The auditory age of children with CIs also influenced the use of these two types of strategies, increasing the use of communication strategies by 0.6% and decreasing the use of educational strategies by 1.2% for each month of increase in the auditory age. In order to foster linguistic development, the SLPs used a wide variety of strategies with the children with CIs, adjusting them to the activity and the auditory age.

The Influence of Caregiver Language on the Association Between Child Temperament and Spoken Language in Children Who Are Deaf or Hard of Hearing

OBJECTIVES

To examine the interaction between child temperament and caregiver linguistic input (i.e., syntactic complexity and lexical diversity) on receptive language in children who are deaf or hard of hearing (DHH).

DESIGN

Families of 59 DHH children ( Mage = 5.66 years) using spoken language for communication participated in this cross-sectional study. Caregivers completed the Child Behavior Questionnaire-Short Form, which measured child temperament across three established factors (i.e., effortful control, negative affectivity, surgency-extraversion) and participated with their child in a semi-structured, dyadic play interaction that occurred during a home visit. Caregivers' language during the play interaction was quantified based on lexical diversity and syntactic complexity. Children also completed norm-referenced receptive language measures (i.e., Comprehensive Assessment of Spoken Language-2, age-appropriate Clinical Evaluation of Language Fundamentals) during the home visit that were combined into a composite measure of child receptive language.

RESULTS

When caregivers used lower to moderate levels of lexical diversity, child effortful control was positively related to child receptive language. However, when caregivers used higher levels of lexical diversity, child effortful control and child receptive language were not related to each other.

CONCLUSIONS

Family environments rich in caregiver lexical input to children might provide a protective influence on DHH child language outcomes by helping to ensure DHH children with varying self-regulatory abilities achieve better spoken language comprehension. These findings highlight the importance of encouraging caregivers to provide rich and stimulating language-learning environments for DHH children.

Efficacy of a Self-Directed Video-Based Caregiver-Implemented Language Programme

INTRODUCTION

Caregiver-implemented language programmes are effective for alleviating early language difficulties. This study examined the efficacy of a self-directed video-based caregiver-implement language programme in Chinese families.

METHOD

This study consisted of two stages. In stage 1, 31 caregiver-child dyads (typically developing children) completed the training programme (group 1) in the form of six video-based training modules. In stage 2, 28 caregiver-child dyads (children with language difficulties) receiving active speech therapy were randomly assigned to the training (group 2) and control arms (group 3). Group 2 received the same training as group 1 in addition to their regular therapy while group 3 was kept as status quo. Caregivers completed a quiz on their knowledge of language facilitation techniques (LFTs) and submitted caregiver-child interaction videos at the start and end of the training. Outcome measures included programme completion rate, quiz scores, and use of LFTs and children's communication skills in the videos. A pre-post design and a between-group design were adopted in the stage 1 and 2 studies, respectively.

RESULTS

A completion rate of about 60% in both stages was noted. Significantly higher post-training knowledge scores were found in groups 1 and 2. General but nonsignificant growth in use of parallel talk and gesture, and significant gains in children's vocalization in the training arm were observed.

CONCLUSION

The self-directed video-based training programme would be useful in imparting information to caregivers. However, the modest improvements in the use of LFTs suggested direct coaching appeared to still play a significant role in enhancing the actual implementation of LFTs. Further investigation on a larger scale is required to evaluate the effectiveness of the training programme for promoting the wider use of this mode as a preventive measure.

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.

From disabled tourists to impaired cyborg tourists: What would it take to transform?

Despite the media reports and governments promoting tourism as a fundamental right for everyone, traveling is still not accessible for disabled people. This study has highlighted the need to make tourists with disabilities accessable for inaccessible destinations. Cyborg products in the form of technological implants can make tourists with disabilities accessable for inaccessible destinations. Since tourists with a mobility disability (TMD) will be one of the primary beneficiaries of technological implants, little is known about their acceptance of technological implants during traveling.Therefore, this study assesses the willingness of TMD to use technological implants during traveling through a qualitative research approach. The results from thematic analysis identified two main themes: the use of assistive devices during traveling with four sub-themes (freedom of traveling, physical and attitudinal barriers, cost, and additional assistance and battery issues), and drivers of impaired cyborg tourists with seven sub-themes (independence, improved well-being, convenience/ease of use, social inclusion, positive emotions, motivation, and other issues). The study contributed to the literature by introducing drivers of impaired cyborg tourists along with previously identified concepts. The results also provided implications for the stakeholders of the tourism industry.

Assessing parent interaction with deaf infants: A quantitative survey of UK professional practice

BACKGROUND

Between 90% and 95% of deaf children are born to hearing parents who often need support with how to adapt their communication. Parent-child interaction (PCI) is an important predictor of deaf children's future language development. It is therefore necessary for professionals to assess parents' strengths and needs to identify areas for intervention. Qualified teachers of the deaf (QToDs), speech and language therapists (SLTs), psychologists, and national deaf child and adolescent mental health (NDCAMHS) professionals regularly support families with deaf children. With no current evidence-based tool available to assist with the assessment of PCI in deafness, it is important to gather information on current professional practice as this may differ from known practices within research.

AIMS

To survey the practices of UK-based professionals in the assessment of PCI where the deaf infant is aged 0-3 years. Professionals were QToDs, SLTs, psychologists or psychiatrists and professionals working at NDCAMHS services.

METHODS & PROCEDURES

After a pilot phase, an 85-item survey was distributed electronically through a range of professional and social media networks. Survey items were based on a systematic review of PCI with deaf infants. Survey questions were focused on parent behaviours that were assessed, methods of assessment, goal planning and service provision. Analysis was conducted using descriptive and inferential statistics.

OUTCOMES & RESULTS

A total of 190 professionals from across the UK completed part 1 of the survey; this decreased to 148 in part 4. Respondents were primarily female, hearing, used spoken English and had 16 years or more experience. Results indicate that PCI is routinely assessed by a large proportion of professionals and there is a substantial overlap in which parent behaviours are assessed. Some parent behaviours are assessed that do not feature in the research. Methods of assessment are informal and predominantly consist of observation and note making, with professionals using their own skills and experience to analyse interaction. Goal setting practices were largely similar between professionals, with many jointly deciding goals with parents.

CONCLUSIONS & IMPLICATIONS

This survey highlights the range of parent behaviours assessed by UK professionals in PCI with deaf children aged 0-3. This survey provides valuable information about and for professionals who assess PCI and set intervention goals with parents. Information from research and professional practice is important to consider in the design of a future PCI assessment. Implications are included for future research in this area.

WHAT THIS PAPER ADDS

What is already known on this subject Parental involvement is one of the greatest predictors of deaf children's language outcomes. With many deaf children born to hearing parents, parents often need guidance with how to facilitate effective communication. A recent systematic review identified the range of parent behaviours and methods used to analyse PCI in international research studies, but little evidence or guidance exists on how professionals assess this phenomenon in practice. What this study adds This is the first survey to generate large, valuable practice-based evidence for the assessment of parents' communication behaviours as they interact with their deaf infants aged 0-3. The survey recruited a range of multidisciplinary professionals working on interaction within this field: SLTs, qualified teachers of the deaf, psychologists or psychiatrists, and professionals working within deaf child and adolescent mental health services. The study reports on which behaviours these professionals assess and how, and includes information on the goal setting behaviours of practitioners. Most respondents were highly experienced; the survey, therefore, reveals expert practice within the field. What are the potential or actual clinical implications of this work? We recommend the following practice: (1) incorporate a range of parent-based behaviours in PCI assessments, including establishing joint engagement and parental sensitivity, as well as communication-focused behaviours; (2) video record PCI assessments where possible to enable professionals and parents to watch and reflect together; (3) following assessment, set parent-focused goals in collaboration with families, ensuring parents' skills, particularly their strengths, are considered. All primary caregivers should be included in the process where possible; and (4) reassess PCI regularly (at least termly) to monitor and encourage families' progress. The timing of reviews should be discussed between parent and professional.

Associations Between Paternal Play and Executive Function in Deaf and Hard of Hearing Children

PURPOSE

Responsive and dynamic aspects of father-child play are associated with behavioral and neurocognitive development in children and could represent an important contributor to executive function (EF) skills for children who are deaf and hard of hearing (DHH). This study examined associations between paternal behaviors during play and EF skills of DHH children and children with typical hearing (TH).

METHOD

Father-child dyads in families with DHH children (n = 30) and TH children (n = 29) participated in a 15-min video-recorded free-play session that was coded for parental behaviors using Parent-Child Interaction Rating Scales and Rough and Tumble Play Quality. Families also completed an age-appropriate version of the Behavior Rating Index of Executive Function as a measure of child EF.

RESULTS

DHH children were rated as having significantly more everyday difficulties with working memory than TH children. Fathers of DHH children were rated as more intrusive during play than fathers of TH children; however, there were no other differences between paternal groups on coded dimensions of father child play. Paternal respect for child autonomy was associated with fewer child difficulties with planning and organization skills and paternal play engagement was associated with fewer child EF difficulties. Moderation analyses revealed that paternal sensitivity was associated with more working memory difficulties and paternal respect for child autonomy was associated with fewer working memory difficulties for DHH children only.

CONCLUSIONS

Paternal play could be an important environmental context for DHH outcomes. Fathers supporting independent play might generally support EF. Paternal engagement in play might also benefit EF. Results highlight paternal behavioral attributes that could lead to potential father-embedded intervention models.

Associations Between Parent Mental State Language and Child Inhibitory Control in Children Who Are Deaf or Hard of Hearing

PURPOSE

Children who are deaf or hard of hearing (D/HH) are at increased risk for neurocognitive delays, which can have cascading effects on development. Associations between neurocognition and the content of parental language-specifically the use of mental state vocabulary-have been observed in typically hearing (TH) children. This study investigated the role of parental use of mental state language (e.g., vocabulary related to thought processes, desires, and emotions) in explaining variability in neurocognition in children who are D/HH.

METHOD

Dyads of 62 TH and 69 D/HH children who wear hearing aids or cochlear implants (ages 3-8 years) and their primary parent were videorecorded during a 20-min play session. Specific mental state words used by parents were extracted. Child neurocognition (specifically, inhibitory control) was assessed using norm-referenced measures.

RESULTS

Parent use of mental state language predicted child inhibitory control differentially based on hearing status, with a significant relation in the D/HH but not the TH group. Mental state vocabulary related to cognition (e.g., "think," "know"), but not to desire (e.g., "want," "like") or emotion (e.g., "feel," "frustrated"), predicted child inhibitory control in the D/HH group. Finally, there was a significant relation between the use of first person, but not second or third person, mental state verbs (e.g., "I think") and child inhibitory control.

CONCLUSIONS

Parental use of cognitive mental state vocabulary models language around thought processes, and parents' use of first-person referents models "self-talk." Modeling of these linguistic forms is likely foundational for developing self-regulation. Children who are D/HH often experience reduced auditory access and/or language delays and thus rely on high-quality parental language input for longer periods of development than their TH peers. Continued support from interventionists is indicated to coach parents to be high-quality models of more abstract, decontextualized language, supporting complex language development and inhibitory control in children who are D/HH.

Development and Validation of a Parenting Stress Module for Parents of Children Using Cochlear Implants

OBJECTIVES

The purpose of this study was to develop and validate a cochlear implant (CI)-specific parenting stress measure using the FDA Guidance on Patient-Reported Outcomes (2009).

METHODS

The development and psychometric validation of the Parenting Stress-CI module for both the Early Childhood (EC; 0-5 years) and School-Age (SA; 6-12 years) versions are reported in this article. Instrument development consisted of qualitative interviews with parents of children with CIs (EC: N = 19; SA: N = 21), content analysis, item development, and cognitive testing of the instrument. Last, we conducted the psychometric validation (EC: N = 72; SA: N = 64), including analyses of internal consistency, test-retest reliability (∼2 weeks between administrations; N = 24), and convergent validity with the Parenting Stress Index-4 (PSI-4).

RESULTS

The final EC version includes 15 questions, and the SA version includes 8 questions. Both the EC and SA versions had strong reliability (EC α = .88; SA α = .85), with all items significantly correlated with the overall module (r = .43-.80). Both versions also had strong test-retest reliability (r = .99, p < .001). Last, analyses of convergent validity demonstrated significant correlations with the PSI-4 Total Stress scale for both Parenting Stress-CI versions (EC r = .66, p < .00; SA r = .45, p < .001).

CONCLUSIONS

The Parenting Stress-CI modules are reliable and valid condition-specific parenting stress instruments for parents of children with CIs ages 0-12 years, filling a significant gap in the literature. These fully validated instruments can be used to assess parental needs for support and guide the development of targeted, family centered interventions.

Predictors of Early Language Outcomes in Children with Connexin 26 Hearing Loss across Three Countries

GJB2-associated hearing loss (GJB2-HL) is the most common genetic cause of hearing loss in children. However, little is known about the clinical characteristics and early language outcomes in population-oriented samples including children with different degrees of hearing loss. Insight into these characteristics are relevant for the counselling of parents. Our sample consisted of 66 children at approximately 2 years of age (17–32 months) with bilateral hearing loss due to GJB2 from three population-based cohorts in Austria, Australia and the Netherlands. Predictors of early vocabulary, including demographic, audiological, genetic and intervention variables and the role of medical comorbidities and nonverbal cognition were examined. The vocabulary scores of children with GJB2-HL were approximately 0.7 standard deviations (SDs) below the norms of children with typical hearing. Age at access to family-centered early intervention and first-born position among siblings predicted language outcomes, whereas the degree of hearing loss and genetic subtype were not significantly correlated with expressive vocabulary. In children with GJB2-HL, early access to family-centered early intervention significantly affected language outcomes at the age of two.

Multidimensional Family-Centred Early Intervention in Children with Hearing Loss: A Conceptual Model

At least two per thousand newborns are affected by hearing loss, with up to 40% with an additional disability. Early identification by universal newborn hearing screening and early intervention services are available in many countries around the world, with limited data on their effectiveness and a lack of knowledge about specific intervention-related determinants of child and family outcomes. This concept paper aimed to better understand the mechanisms by which multi-dimensional family-centred early intervention influences child outcomes, through parent behaviour, targeted by intervention by a review of the literature, primarily in the field of childhood hearing loss, supplemented by research findings on physiological and atypical child development. We present a conceptual model of influences of multi-disciplinary family-centred early intervention on family coping/functioning and parent–child interaction, with effects on child psycho-social and cognitive outcomes. Social communication and language skills are postulated as mediators between parent–child interaction and non-verbal child outcomes. Multi-disciplinary networks of professionals trained in family-centred practice and the evaluation of existing services, with respect to best practice guidelines for family-centred early intervention, are recommended. There is a need for longitudinal epidemiological studies, including specific intervention measures, family behaviours and multidimensional child outcomes.

A Framework for Understanding the Relation Between Spoken Language Input and Outcomes for Children with Cochlear Implants

Spoken language outcomes after cochlear implantation are highly variable. Some variance can be attributed to individual characteristics. Research with typically hearing children suggests that the amount of language directed to children may also play a role. However, several moderating factors may complicate the association between language input and language outcomes in children with cochlear implants. In this article, I present a conceptual framework that posits that the association between total language input directed to children and language outcomes is moderated by factors that influence what is accessible, attended to, and coordinated with the child. The framework also posits that children with cochlear implants exhibit more variability on those moderating factors, which explains why the relation between language input and language outcomes may be more complex even if language input is more important for successful language outcomes in this population.

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.

An Integrative Review of Current Practice Models and/or Process of Family-Centered Early Intervention for Children Who Are Deaf or Hard of Hearing

Over the past few decades, there has been an increasing shift toward emphasizing the importance of the child's family taking an active role in the habilitation process through family-centered early intervention (FCEI) programs. Accordingly, the Health Professions Council of South Africa recommends that early intervention services following confirmation of hearing loss must be family-centered within a community-based model of service delivery that is culturally congruent. The aim of this study was to explore and document current evidence reflecting trends in FCEI for children who are deaf or hard of hearing (DHH) by identifying and describing current practice models and/or processes of FCEI for these children. This study describes our first steps in formulating a framework for FCEI for children who are DHH in South Africa. An integrative literature review was conducted. Sage, Science Direct, PubMed, and Google Scholar databases were searched for studies published in English between January 2009 and January 2019 reporting on FCEI programs for children who are DHH. Studies that focused on the following were excluded from the study: speech and language outcomes of children, youth, and adults who are DHH; education for children who are DHH; universal newborn hearing screening; professionals' roles in early hearing detection and intervention; diagnosis of hearing loss; and sign language. Kappa statistics were performed to determine agreement between reviewers. Twenty-two studies were included in the review. Cohen's kappa revealed a substantial agreement (κ = 0.8) between reviewers for data extraction and synthesis in terms of the articles that met the criteria for inclusion in the review. Findings were discussed under 5 themes: caregiver involvement; caregiver coaching/information sharing; caregiver satisfaction; challenges with FCEI; and telehealth. Generally, there is sufficient evidence for FCEI, with caregivers indicating the need for full involvement in their children's care. Methods of caregiver involvement involving caregiver coaching/information sharing need to be culturally and linguistically appropriate, with sensitivities around time and manner. This increases caregiver satisfaction with intervention programs and improves outcomes for children who are DHH. Challenges identified by the studies raise implications for early hearing detection and intervention programs, as well as Departments of Health and Social Welfare. These included logistical challenges, professional-related challenges, and caregiver-related challenges. Various aspects of FCEI have been reported in the review. Findings of these studies have significant implications for the formulation of quality FCEI programs to ensure contextually relevant and contextually responsive care of children who are DHH.

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.

Differential At-Risk Pediatric Outcomes of Parental Sensitivity Based on Hearing Status

Purpose The aim of this study was to investigate the role of parental sensitivity in language and neurocognitive outcomes in children who are deaf and/or hard of hearing (DHH). Method Sixty-two parent-child dyads of children with normal hearing (NH) and 64 of children who are DHH (3-8 years) completed parent and child measures of inhibitory control/executive functioning and child measures of sentence comprehension and vocabulary. The dyads also participated in a video-recorded, free-play interaction that was coded for parental sensitivity. Results There was no evidence of associations between parental sensitivity and inhibitory control or receptive language in children with NH. In contrast, parental sensitivity was related to children's inhibitory control and all language measures in children who are DHH. Moreover, inhibitory control significantly mediated the association between parental sensitivity and child language on the Clinical Evaluation of Language Fundamentals-Fifth Edition Following Directions subscale (6-8 years)/Clinical Evaluation of Language Fundamentals Preschool-Second Edition Concepts and Following Directions subscale (3-5 years). Follow-up analyses comparing subgroups of children who used hearing aids (n = 29) or cochlear implants (CIs; n = 35) revealed similar correlational trends, with the exception that parental sensitivity showed little relation to inhibitory control in the group of CI users. Conclusions Parental sensitivity is associated with at-risk language outcomes and disturbances in inhibitory control in young children who are DHH. Compared to children with NH, children who are DHH may be more sensitive to parental behaviors and their effects on emerging inhibitory control and spoken language. Specifically, inhibitory control, when scaffolded by positive parental behaviors, may be critically important for robust language development in children who are DHH.

Do Acoustic Environment Characteristics Affect the Lexical Development of Children With Cochlear Implants? A Longitudinal Study Before and After Cochlear Implant Activation

Purpose This study investigates the acoustic environment of children with cochlear implants (CIs) and the relationship between exposure to speech, in noise and in quiet, and the children's lexical production up to 1 year after CI activation, while controlling for the effect of early individual differences in receptive vocabulary growth. Method Eighteen children with CIs were observed at 3, 6, and 12 months after CI activation. Children's spontaneous word production during interaction with their mothers (types and tokens) and their expressive and receptive vocabulary size were considered. The characteristics of the acoustic environments in terms of acoustic scenes (speech in noise or in quiet, quiet, noise, music, and other) and of loudness ranges were assessed using data logging of the children's devices. Results Data analysis showed that both the number of tokens and the number of types produced 1 year after CI activation were affected by the children's exposure to speech in quiet with a loudness range between 40 and 69 dB. Expressive vocabulary size and types were affected by the receptive vocabulary knowledge that the children achieved over the first 3 months after CI activation. Conclusions Our data support the role of speech environment and individual differences in early comprehension on lexical production. The importance of exposure to speech with particular characteristics for the lexical development of children with CIs and the implications for clinical practice are discussed.

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.

The interplay between early social interaction, language and executive function development in deaf and hearing infants

In this article, we review the influence of early social interaction on the development of executive function and language in infants. We first define social interaction, executive function and language and show how they are related in infant development. Studies of children born deaf are used to illustrate this connection because they represent cases where there has been a disruption to early social interaction and the development of intersubjectivity. Unlike other groups, the disturbance to development is known to be largely environmental rather than neuro-biological. This enables us to more accurately tease apart those impacts on EF that are associated with social interaction and language, since the potential confounds of disordered cognitive development are largely controlled for. The review offers a unifying model for how social, cognitive and linguistic development work together in early human development.

Positive Parenting Behaviors: Impact on the Early Vocabulary of Infants/Toddlers With Cochlear Implants

Purpose To extend our knowledge about factors influencing early vocabulary development for infants with cochlear implants (CIs), we investigated the impact of positive parenting behaviors (PPBs) from the Indicator of Parent Child Interaction, used in parent-child interactions during everyday activities. Method Implantation age for the sample recruited from CI clinics in Australia ranged from 6 to 10 months for 22 children and from 11 to 21 months for 11 children. Three observation sessions at three monthly intervals were coded for use of PPBs. Children's productive vocabulary, based on the MacArthur-Bates Communicative Development Inventories parent checklist, was collected approximately 6 and 9 months later. A repeated-measures negative binomial generalized linear mixed-effects model was used to investigate associations between the total PPBs per session, covariates (maternal education, gender, and time since implant), and the number of words produced. In follow-up analyses with the PPBs entered separately, variable selection was used to retain only those deemed informative, based on the Akaike information criterion. Results As early as Session 1, associations between the PPBs and vocabulary were identified. Time since implant had a positive effect. For different sessions, specific PPBs (descriptive language, follows child's lead, and acceptance and warmth) were identified as important contributors. Conclusions Complementing previous findings, valuable information was identified about parenting behaviors that are likely to impact positively the early vocabulary of infants with CIs. Of importance is providing parents with information and training in skills that have the potential to help create optimal contexts for promoting their child's early vocabulary development.

Effects of Parents' Mealtime Conversation Techniques for Preschool Children With Hearing Loss Who Use Listening and Spoken Language

Purpose This mixed-methods study aimed to examine the conversation techniques used by parents of young children with hearing loss (HL) during dinnertime at home. Parents' usage rates of open- and closed-ended language elicitation, reformulation, imitation, directives, and explicit vocabulary instruction were examined in relation to children's receptive vocabulary and basic-concepts skills. Method Twenty-minute dinnertime segments were extracted from naturalistic, daylong recordings of 37 preschoolers with HL who used listening and spoken language. The segments were hand-coded for parents' use of conversation techniques. Children's receptive vocabulary and basic concepts were assessed using standardized measures. Results Parents' use of conversation techniques varied widely, with closed-ended elicitation and directives used most frequently during dinner. Explicit vocabulary instruction was correlated with general receptive vocabulary and basic-concepts skills. Thematic analysis of the conversations revealed common themes, including concrete topics and sibling speakers. In addition, parents who used many techniques often introduced abstract conversation topics; electronic media was present in all conversations with few techniques. Conclusions Parents of preschoolers with HL may benefit from specific coaching to elicit language and introduce new vocabulary during home routines. These techniques may help develop their children's receptive language.

Family-Level Executive Functioning and At-Risk Pediatric Hearing Loss Outcomes

Purpose Using a new measure of family-level executive functioning (EF; the Family Characteristics Scale [FCS]), we investigated associations between family-level EF, spoken language, and neurocognitive skills in children with hearing loss (HL), compared to children with normal hearing. Method Parents of children with HL (n = 61) or children with normal hearing (n = 65) completed the FCS-Parent, and clinicians evaluated families using the FCS-Examiner. Children completed an age-appropriate version of the Concepts and Following Directions subtest of the Clinical Evaluation of Language Fundamentals and the Peabody Picture Vocabulary Test-Fourth Edition. Child EF was assessed via the parent report Behavior Rating Inventory of Executive Function. Results Two higher order components were derived from FCS subscales: Family Inhibition and Family Organization. For both samples, Family Inhibition was positively associated with child inhibition, child shifting, and child language comprehension skills. Family Organization was differentially associated with child inhibition, working memory, and planning/organization skills across the samples. Additionally, Family Inhibition was associated with child planning and organization skills for children with HL. Conclusions Results support the FCS as a measure of family-level EF. Family-level inhibition related to better child inhibition, flexibility/shifting, and language comprehension across both samples and to better planning and organization skills in children with HL. As children with HL experienced greater difficulties in EF, families demonstrated greater organization, possibly as a compensatory measure. Results suggest that inhibition and organization at a family level may be important targets for the development of novel interventions to promote EF and language outcomes for children with HL.

Receptive and Expressive Language in Hindi Speaking Children with Postcochlear Implantation at 6-Month Intervals

Introduction  Individual variability in the language outcomes of children with cochlear implantation (CI) is a major concern. In CI rehabilitation, there is lack of a protocol regarding uniform post-CI language assessment interval duration, which can ensure better understanding of the trajectory of language growth as well as optimize language outcomes by providing feedback in fine tuning the language intervention program.

Objective  To evaluate the receptive and expressive language in Hindi speaking children with up to 2 years of CI experience using revised receptive-expressive emergent language test-3ed. (REELT-3) at 6 months intervals and to compare it with that of children with normal hearing (NH).

Methods  The present study included 192 children divided in 2 groups, 96 children with CI (15.8 ± 6.7 months), and 96 age-matched children with NH (22.3 ± 7.9 months). A cross-sectional, prospective study design was used to measure the language ability score (LAS) at an interval of 6 months from the time of implantation (TIA), which is 0 to 6 months, 7 to 12 months, 13 to 18 months, and 19 to 24 months of CI usage.

Results  The two-way analysis of variance revealed that the LAS after 18 months of CI usage was similar to (F (3, 92) = 8.63, p  = 0.19, ηp2 = 0.028) that of the children with NH. However, other demographic factors, for instance, gender (F (3, 92) = 1.73, p  = 0.505, ηp2 = 0.002), parent's education, (F (3, 92) = 2.05, p  = 0.937, ηp2 = 0.031), and financial background (F (3, 92) = 2.49, p  = 0.351, ηp2 = 0.076) had no major impact on language.

Conclusion  Eighteen months of CI usage duration can potentially stimulate receptive and expressive language up to age-matched children with NH. A protocol of periodic assessment of language, at least of 6 months, may be developed to optimize language outcomes.

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.

Global Regulatory Review Needed for Cochlear Implants: A Call for FDA Leadership

INTRODUCTION

Using the United States Food and Drug Administration (FDA) as example, we argue that regulatory agencies worldwide should review their guidance on cochlear implants (CIs).

METHODS

This is a position paper, thus the methods are strictly argumentation. Here we give the motivation for our recommendation. The FDA's original approval of implantation in prelingually deaf children was granted without full benefit of information on language acquisition, on childcaregiver communication, and on the lived experience of being deaf. The CI clinical trials, accordingly, did not address risks of linguistic deprivation, especially when the caregiver's communication is not fully accessible to the prelingually deaf child. Wide variability in the effectiveness of CIs since initial and updated approval has been indicated but has not led to new guidance. Children need to be exposed frequently and regularly to accessible natural language while their brains are still plastic enough to become fluent in any language. For the youngest infants, who are not yet producing anything that could be called language although they might be producing salient social signals (Goldstein et al. Child Dev 80:636-644, 2009), good comprehension of communication from caregiver to infant is critical to the development of language. Sign languages are accessible natural languages that, because they are visual, allow full immersion for deaf infants, and they supply the necessary support for this comprehension. The main language contributor to health outcomes is this combination of natural visual language and comprehension in communication. Accordingly, in order to prevent possible language deprivation, all prelingually deaf children should be exposed to both sign and spoken languages when their auditory status is detected, with sign language being critical during infancy and early childhood. Additionally, all caregivers should be given support to learn a sign language if it is new to them so that they can comprehend their deaf children's language expressions fully. However, both languages should be made accessible in their own right, not combined in a simultaneous or total communication approach since speaking one language and signing the other at the same time is problematic.

RESULTS

Again, because this is a position paper, our results are our recommendations. We call for the FDA (and similar agencies in other countries) to review its approval of cochlear implantation in prelingually deaf children who are within the sensitive period for language acquisition. In the meantime, the FDA should require manufacturers to add a highlighted warning to the effect that results with CI vary widely and CIs should not be relied upon to provide adequate auditory input for complete language development in all deaf children. Recent best information on users' experience with CIs (including abandonment) should be clearly provided so that informed decisions can be made. The FDA should require manufacturers' guidance and information materials to include encouragement to parents of deaf children to offer auditory input of a spoken language and visual input of a sign language and to have their child followed closely from birth by developmental specialists in language and cognition. In this way parents can align with providers to prioritize cognitive development and language access in both audio-vocal and visuo-gestural modalities.

DISCUSSION

The arguments and recommendations in this paper are discussed at length as they come up.

Communication Skills and Communicative Autonomy of Prelinguistic Deaf and Hard-of-Hearing Children: Application of a Video Feedback Intervention

Background and Aim

Evidence on the efficacy of parenting interventions to support communication development in deaf and hard-of-hearing children is emerging. In previous research, we showed that parental participation in a video feedback-based intervention enhanced parental self-esteem and emotional availability to their deaf and hard-of-hearing children. This paper investigates the impact of the intervention on the development of the children's prelingual communication skills and autonomy. Evidence on the efficacy of parenting interventions to support communication development is warranted.

Methods

Sixteen hearing parents with a prelingual deaf and hard-of-hearing child (Mage = 2.05 years, SD = 1.77) were recruited by self-selection from pediatric audiological services and randomly stratified into intervention-first and waiting-list groups. Families completed three sessions of Video Interaction Guidance in their homes. Designed for maximal inclusion, the sample comprised children with complex developmental and social needs. The primary inclusion criterion was the child's prelingual status (<50 signed/spoken words), which was established using speech and language therapy reports. Child communicative autonomy was assessed from a 20 min free-play video recording using a gold standard measure for deaf and hard-of-hearing children (Tait) before and after the intervention.

Results

A Mann-Whitney U test indicated no significant difference between the two groups. The groups were collated, and a Wilcoxon signed-rank test with time (pre-/post-intervention) as a repeating variable was run. A significant increase in children's communicative autonomy (Z = -3.517, p < 0.0001, d = 0.62) and decrease in children's no-responses (Z = -3.111, p < 0.005, d = 0.55) were seen. There was no significant difference in the overall number of turn-taking between the parent and child, indicating differences in the quality of the parent-child interactions, not the quantity.

Conclusion

This study adds to the emerging evidence for parenting interventions with deaf and hard-of-hearing children. We hypothesize that the video feedback intervention with its focus on emotional availability created space for the children to show increased communicative autonomy during parent-child interactions. Communicative autonomy is a long-term predictor of communication and linguistic development in deaf and hard-of-hearing children, and its conceptual underpinning makes it a good early measure of relational agency. Results can inform wider interventions that focus on the quantity of the parent-child communication.

Natural Language Input: Maternal Education, Socioeconomic Deprivation, and Language Outcomes in Typically Developing Children

Purpose The current study was designed to investigate the differences in language input related to family factors (maternal level of education [MLE] and socioeconomic level of deprivation [SLD]) and their association with language outcomes in preschoolers. Method This study used New Zealand SLD and MLE classification systems to examine differences in language input related to these factors among 20 typically developing preschool children aged 2-5 years. The quantity of children's language input (adult words [AWs], conversational turns [CTs]) was calculated using the Language ENvironment Analysis audiotaping technology for two typical weekend days. Four 5-min Language ENvironment Analysis recording segments were transcribed and coded, and parental language strategies were classified as optimal language strategy, moderate language strategy, or sub-optimal language strategy (S-OLS) for child language outcomes. The receptive and expressive language of each child was assessed using the Preschool Language Scales-Fifth Edition. Results Mann-Whitney U tests showed significant differences between the quantity of language input (AWs/hr, CTs/hr) for high and low MLE and high and low SLD groups. Consistent with the literature, the use of S-OLSs was significantly lower for families with high MLE (Mdn = .25, IQR = .14) and low SLD (Mdn = .22, IQR = .13) than for families with low MLE (Mdn = .41, IQR = .24) and high SLD (Mdn = .41, IQR = .26). Spearman correlation coefficients indicated significant associations between language input (AWs/hr, CTs/hr, S-OLSs) and language outcomes. Conclusions Reduced language input and the frequent use of S-OLSs associated with low maternal education and high deprivation and low language outcomes for these children highlight the importance for all parents/families to learn optimal language strategies to support the development of strong language skills in their children in young age.

Parental Linguistic Input and Its Relation to Toddlers' Visual Attention in Joint Object Play: A Comparison Between Children with Normal Hearing and Children With Hearing Loss

Parent-child interactions are multimodal, often involving coordinated exchanges of visual and auditory information between the two partners. The current work focuses on the effect of children's hearing loss on parent-child interactions when parents and their toddlers jointly played with a set of toy objects. We compared the linguistic input received by toddlers with hearing loss (HL) and their chronological age-matched (CA) and hearing age-matched (HA) normal-hearing peers. Moreover, we used head-mounted eye trackers to examine how different parental linguistic input affected children's visual attention on objects when parents either led or followed children's attention during joint object play. Overall, parents of children with HL provided comparable amount of linguistic input as parents of the two normal-hearing groups. However, the types of linguistic input produced by parents of children with HL were similar to the CA group in some ways and similar to the HA group in other ways. Interestingly, the effects of different types of linguistic input on extending the attention of children with HL qualitatively resembled the patterns seen in the CA group, even though the effects were less pronounced in the HL group. We discuss the implications of these results for our understanding of the reciprocal, dynamic, and multi-factored nature of parent-child interactions.

Early Vocabulary Profiles of Young Deaf Children Who Use Cochlear Implants

Purpose This study examined vocabulary profiles in young cochlear implant (CI) recipients and in children with normal hearing (NH) matched on receptive vocabulary size to improve our understanding of young CI recipients' acquisition of word categories (e.g., common nouns or closed-class words). Method We compared receptive and expressive vocabulary profiles between young CI recipients (n = 48; mean age at activation = 15.61 months, SD = 4.20) and children with NH (n = 48). The two groups were matched on receptive vocabulary size as measured by the MacArthur-Bates Communicative Development Inventories (Fenson et al., 2006): Words and Gestures form. The CI group had, on average, 8.98 months of hearing experience. The mean chronological age at completing the MacArthur-Bates Communicative Development Inventories was 23.99 months (SD = 5.14) for the CI group and 13.72 months (SD = 1.50) for the NH group. Results The CI group had a larger expressive vocabulary size than the receptive vocabulary size-matched NH group. The larger expressive vocabulary size was associated with the group difference in social words but not with common nouns. The analyses for predicate words and closed-class words included only children who produced the target categories. The CI group had a larger proportion of predicate words than the NH group, but no difference was found in closed-class words in expressive vocabulary. Conclusions Differences found in expressive vocabulary profiles may be affected by spoken vocabulary size and their age. A further examination is warranted using language samples to understand the effect of language input on children's vocabulary profiles.

Lexical Repetition Properties of Caregiver Speech and Language Development in Children With Cochlear Implants

Purpose Early language input plays an important role in child language and cognitive development (e.g., Gilkerson et al., 2018; Hart & Risley, 1995). In this study, we examined the effects of child's hearing status on lexical repetition properties of speech produced by their caregivers with normal hearing (NH). In addition, we investigated the relationship between maternal lexical repetition properties and later language skills in English-learning infants with cochlear implants (CIs). Method In a free-play session, 17 mothers and their prelingually deaf infants who received CIs before 2 years of age (CI group) were recorded at two post-CI intervals: 3 and 6 months postactivation; 18 hearing experience-matched infants with NH and their mothers and 14 chronological age-matched infants with NH group and their mothers were matched to the CI group. Maternal speech was transcribed from the recordings, and measures of maternal lexical repetition were obtained. Standardized language assessments were administered on children with CIs approximately two years after CI activation. Results The findings indicated that measures of lexical repetition were similar among the three groups of mothers, regardless of the hearing status of their infants. In addition, lexical repetition measures were correlated with later language skills in infants with CIs. Conclusions Infants with CIs receive the language input that contains similar lexical repetition properties as that in the speech received by their peers with NH, which is likely to play an important role in child speech processing and language development. These findings provide the knowledge for professionals to coach parents to implement specific language intervention strategies to support language development in infants with hearing loss. Supplemental Material https://doi.org/10.23641/asha.11936322.

Cochlear implants before 9 months of age led to more natural spoken language development without increased surgical risks

AIM

Evidence suggests that cochlear implants are beneficial for language development, but there is no consensus about the ideal age for surgery. We investigated how language development and surgical safety were affected by patients' ages.

METHODS

This study comprised 103 children (52 boys) aged 4.3-16 years who received cochlear implants at 5-29 months at the Karolinska University Hospital, Stockholm, Sweden, between 2002 and 2013. All showed typical development and were from monolingual homes. Bilateral implants were common (95%). The children were regularly assessed on language understanding, vocabulary and speech recognition by a multi-disciplinary team for 10.0 ± 3.7 (4.7-16.0) years.

RESULTS

There were no associations between complications after surgery and the age when children had their first implant. Children implanted at 5-11 months reached an age-equivalent level of language understanding and better vocabulary outcome sooner than subgroups implanted later. Children who had surgery at 12-29 months demonstrated more atypical and delayed language abilities over time. Early implantation, preferably before 9 months, may lead to a more typical trajectory of spoken language development.

CONCLUSION

Our findings showed that cochlear implantation before 9 months was safe. Early implantation may reduce the negative effects of auditory deprivation and promotes more natural and synchronised language development.

Associations Between Parenting Stress, Language Comprehension, and Inhibitory Control in Children With Hearing Loss

Purpose Parenting stress has been studied as a potential predictor of developmental outcomes in children with normal hearing and children who are deaf and hard of hearing. However, it is unclear how parenting stress might underlie at-risk spoken language and neurocognitive outcomes in this clinical pediatric population. We investigated parenting stress levels and the shared relations between parenting stress, language comprehension, and inhibitory control skills in children with and without hearing loss (HL) using a cross-sectional design. Method Families of children with HL (n = 39) and with normal hearing (n = 41) were tested. Children completed an age-appropriate version of the Concepts & Following Directions subtest of the Clinical Evaluation of Language Fundamentals and the NIH Toolbox Flanker Test of Attention and Inhibitory control. Caregivers completed the Parenting Stress Index-Short Form 4. Results Parenting stress levels were not significantly different between parents of children with and without HL. A significant negative association was observed between parenting stress and our measure of language comprehension in children with HL. A negative association between parenting stress and inhibitory control skills was also found in families of children with HL, but not hearing children. The parenting stress-inhibitory control relationship was indirectly accounted for by delayed language comprehension skills in children with HL. Conclusion Even at moderate levels of parenting stress similar to parents of children with normal hearing, increases in parenting stress were associated with lower scores on our measures of language comprehension and inhibitory control in children with HL. Thus, parenting stress may underlie some of the variability in at-risk pediatric HL outcomes.

Talk with me! Parental linguistic input to toddlers with moderate hearing loss

This study examined the quantity and quality of parental linguistic input to toddlers with moderate hearing loss (MHL) compared with toddlers with normal hearing (NH). The linguistic input to eighteen toddlers with MHL and twenty-four toddlers with NH was examined during a 10-minute free-play activity in their home environment. Results showed that toddlers with MHL were exposed to an equivalent amount of parental linguistic input compared to toddlers with NH. However, parents of toddlers with MHL used less high-level facilitative language techniques, used less mental state language, and used shorter utterances than parents of toddlers with NH. Quantity and quality measures of parental linguistic input were positively related to the expressive language abilities of toddlers with MHL.

Effects of children's hearing loss on the synchrony between parents' object naming and children's attention

Children's attentional state during parent-child interactions is important for word learning. The current study examines the real-time attentional patterns of toddlers with and without hearing loss (N = 15, age range: 12-37 months) in parent-child interactions. High-density gaze data recorded from head-mounted eye-trackers were used to investigate the synchrony between parents' naming of novel objects and children's sustained attention on the named objects in joint play. Results show that the sheer quantities of parents' naming and children's sustained attention episodes were comparable in children with hearing loss and their peers with normal hearing. However, parents' naming and children's sustained attention episodes were less synchronized in the hearing loss group compared to children with normal hearing. Possible implications are discussed.

Analysis of Amount and Style of Oral Interaction Related to Language Outcomes in Children With Hearing Loss: A Systematic Review (2006-2016)

Purpose This systematic review summarizes the evidence for differences in the amount of language input between children with and without hearing loss (HL). Of interest to this review is evaluating the associations between language input and language outcomes (receptive and expressive) in children with HL in order to enhance insight regarding what oral language input is associated with good communication outcomes. Method A systematic review was conducted using keywords in 3 electronic databases: Scopus, PubMed, and Google Scholar. Keywords were related to language input, language outcomes, and HL. Titles and abstracts were screened independently, and full-text manuscripts meeting inclusion criteria were extracted. An appraisal checklist was used to evaluate the methodological quality of studies as poor, good, or excellent. Results After removing duplicates, 1,545 study results were extracted, with 27 eligible for full-text review. After the appraisal, 8 studies were included in this systematic review. Differences in the amount of language input between children with and without HL were noted. Conversational exchanges, open-ended questions, expansions, recast, and parallel talk were positively associated with stronger receptive and expressive language scores. The quality of evidence was not assessed as excellent for any of the included studies. Conclusions This systematic review reveals low-level evidence from 8 studies that specific language inputs (amount and style) are optimal for oral language outcomes in children with HL. Limitations were identified as sample selection bias, lack of information on control of confounders and assessment protocols, and limited duration of observation/recordings. Future research should address these limitations.

Comparisons of IQ in Children With and Without Cochlear Implants: Longitudinal Findings and Associations With Language

OBJECTIVES

To make longitudinal comparisons of intelligence quotient (IQ) in children with cochlear implants (CIs) and typical hearing peers from early in development to the school-age period. Children with additional comorbidities and CIs were also evaluated. To estimate the impact of socioeconomic status and oral language on school-age cognitive performance.

DESIGN

This longitudinal study evaluated nonverbal IQ in a multicenter, national sample of 147 children with CIs and 75 typically hearing peers. IQ was evaluated at baseline, prior to cochlear implantation, using the Bayley Scales of Infant and Toddler Development and the Leiter International Performance Scale. School-age IQ was assessed using the Wechsler Intelligence Scales for Children. For the current study, only the Perceptual Reasoning and Processing Speed indices were administered. Oral language was evaluated using the Comprehensive Assessment of Spoken Language.

RESULTS

Children in the CI group scored within the normal range of intelligence at both time points. However, children with additional comorbidities scored significantly worse on the Processing Speed, but not the Perceptual Reasoning Index. Maternal education and language were significantly related to school-age IQ in both groups. Importantly, language was the strongest predictor of intellectual functioning in both children with CIs and normal hearing.

CONCLUSION

These results suggest that children using cochlear implants perform similarly to hearing peers on measures of intelligence, but those with severe comorbidities are at-risk for cognitive deficits. Despite the strong link between socioeconomic status and intelligence, this association was no longer significant once spoken language performance was accounted for. These results reveal the important contributions that early intervention programs, which emphasize language and parent training, contribute to cognitive functioning in school-age children with CIs. For families from economically disadvantaged backgrounds, who are at-risk for suboptimal outcomes, these early intervention programs are critical to improve overall functioning.

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.

Predictors of Vocabulary Outcomes in Children Who Are Deaf or Hard of Hearing From Spanish-Speaking Families

Purpose

The goal of this study was to identify predictors of expressive vocabulary in young Spanish-speaking children who are deaf or hard of hearing living in the United States.

Method

This cross-sectional study considered 53 children with bilateral hearing loss between 8 and 34 months of age ( M = 24, SD = 6.9). Demographic variables, variables related to the hearing loss, and intervention variables were included in a hierarchical regression analysis to predict expressive vocabulary quotients from the MacArthur Inventario del Desarrollo de Habilidades Comunicativas (Communicative Development Inventories; Jackson-Maldonado et al., 2003 ).

Results

Chronological age, degree of hearing loss, functional hearing ability ratings, age of enrollment in early intervention, and the interaction between chronological age and age of intervention accounted for 61.5% of the vocabulary variance. Children who received intervention by 6 months of age achieved significantly higher vocabulary outcomes than children who started intervention later.

Conclusion

The children's mean vocabulary outcomes were below average when compared with hearing peers. This was especially true for older children, children with moderately-severe-to-profound hearing loss, and children who began intervention after 6 months of age. This delay in vocabulary outcomes has the potential to interfere with future reading and academic outcomes.

Parent–Child Interaction Therapy as a Behavior and Spoken Language Intervention for Young Children With Hearing Loss

Purpose

The importance of early intervention for fostering language in children with hearing loss has been well documented; those that facilitate parent engagement are particularly effective. Listening and spoken language outcomes among children with hearing loss continue to fall short compared to hearing peers, despite improvements in hearing technologies. The current study evaluated the effectiveness of parent–child interaction therapy (PCIT) as a behavioral intervention for children with hearing loss and its applicability as a language intervention.

Method

PCIT effectiveness was evaluated for children with hearing loss (PCIT treatment group: N = 18). For a subset of the treatment group (matched experimental group: n = 6), pretreatment and posttreatment language samples were compared to a matched control group ( n = 6).

Results

Significant changes were observed in parent skills and child behavior from pretreatment to posttreatment for the PCIT treatment group. A subset of the treatment group (matched experimental group) with available matched controls (matched control group) demonstrated a significant increase in utterances and a trend toward significant increase in receptive vocabulary compared to the control group.

Conclusion

PCIT is a promising intervention for children with hearing loss that empowers parents to engage in optimal indirect language stimulation, improves parent–child interactions, improves child behavior, and promotes spoken language skills.

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.

A Longitudinal Investigation of the Home Literacy Environment and Shared Book Reading in Young Children With Hearing Loss

OBJECTIVES

The principle goal of this longitudinal study was to examine parent perceptions of home literacy environment (e.g., frequency of book reading, ease of book reading with child) and observed behaviors during shared book reading (SBR) interactions between parents and their children with hearing loss (HL) as compared with parents and their children with normal hearing (NH) across 3 time points (12, 24, and 36 months old). Relationships were also explored among home literacy environment factors and SBR behaviors and later language outcomes, across all three time points for parents of children with and without HL.

DESIGN

Participants were a group of parents and their children with HL (N = 17) and typically developing children with NH (N = 34). Parent perceptions about the home literacy environment were captured through a questionnaire. Observed parent behaviors and their use of facilitative language techniques were coded during videotaped SBR interactions. Children's oral language skills were assessed using a standardized language measure at each time point.

RESULTS

No significant differences emerged between groups of parents (HL and NH) in terms of perceived home literacy environment at 12 and 36 months. However, significant group differences were evident for parent perceived ease of reading to their child at 24 months. Group differences also emerged for parental SBR behaviors for literacy strategies and interactive reading at 12 months and for engagement and interactive reading at 36 months, with parents of children with HL scoring lower in all factors. No significant relationships emerged between early home literacy factors and SBR behaviors at 12 months and oral language skills at 36 months for parents of children with NH. However, significant positive relationships were evident between early home literacy environment factors at 12 months and oral language skills at 36 months for parents and their children with HL.

CONCLUSIONS

Although both groups of parents increased their frequency of SBR behaviors over time, parents of children with HL may need additional support to optimize SBR experiences to better guide their toddlers' and preschoolers' language skills. Early intervention efforts that focus on SBR interactions that are mutually enjoyed and incorporate specific ways to encourage parent-child conversations will be essential as children with HL acquire language.