The effect of early confirmation of hearing loss on the behaviour in middle childhood of children with bilateral hearing impairment

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

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

Study Protocol: Type 1 Hybrid Effectiveness-Implementation Trial of a Behavioral Parent Training Intervention for Parents of Young Children Who Are Deaf or Hard of Hearing

PURPOSE

Children who are deaf or hard of hearing (DHH) and who use hearing aids or cochlear implants are more likely than their peers with typical hearing to exhibit behavior problems. Although multiple evidence-based interventions for child behavior problems exist, they are rarely delivered to children who are DHH, and no rigorous randomized controlled trials have been conducted to determine their effects with this population. This protocol describes a study aiming to test the effectiveness of an evidence-based behavioral parent training intervention adapted for parents of young children who are DHH and simultaneously to assess key implementation outcomes and multilevel contextual factors influencing implementation.

METHOD

The protocol for a Type 1 hybrid effectiveness-implementation trial of a behavioral parent training intervention for parents of young children who are DHH is presented, including details of the study design, participants, assessments, and analyses. Using a stakeholder-engaged, mixed-methods approach, we will test the effects of the intervention versus treatment as usual on parenting behaviors, child behaviors, and a range of secondary effectiveness outcomes, including adherence to using hearing aids and cochlear implants as well as measures of child speech and language. We will assess the acceptability, feasibility, fidelity, and costs of the intervention from the perspectives of peer coaches who deliver the intervention, hearing health care clinicians (including audiologists and speech-language pathologists), and administrators of programs serving young children who are DHH.

CONCLUSIONS

Results of this trial will inform future efforts to close the gap between prevalence of behavioral problems in young children who are DHH and access to and use of evidence-based interventions to prevent and treat them. If effective, this intervention could be widely implemented using strategies informed by the findings of this study to benefit young children who are DHH and followed in hearing health care and their families.

Emotions in Deaf and Hard-of-Hearing and Typically Hearing Children

For deaf and hard-of-hearing (DHH) children living in an environment where their access to linguistic input and social interactions is compromised, learning emotions could be difficult, which may further affect social functioning. To understand the role of emotion in DHH children's social life, this study investigated emotional functioning (i.e., emotion recognition, empathy, emotion expression), and its relation with social functioning (i.e., social competence and externalizing behaviors), in 55 DHH children and 74 children with typical hearing (aged 3-10 years; Mage = 6.04). Parental reports on children's emotional and social functioning and factors related to DHH children's hearing were collected. Results showed similar levels of emotional and social functioning in children with and without hearing loss. Use of auditory intervention and speech perception did not correlate with any measures in DHH children. In both groups, higher levels of empathy related to higher social competence and fewer externalizing behaviors; emotion recognition and positive emotion expression were unrelated to either aspect of social functioning. Higher levels of negative emotion expression related to lower social competence in both groups, but to more externalizing behaviors in DHH children only. DHH children in less linguistically accessible environments may not have adequate knowledge for appropriately expressing negative emotions socially.

Outcomes of Universal Newborn Screening Programs: Systematic Review

BACKGROUND

This systematic review examined the outcomes (age of identification and intervention, developmental outcomes, cost-effectiveness, and adverse effects on parents) of universal newborn hearing screening (UNHS) for children with permanent congenital hearing loss (PCHL).

MATERIALS AND METHODS

Multiple electronic databases were interrogated in March and April 2020 with further reports identified from article citations and unpublished literature. UNHS reports in English with comparisons of outcomes of infants who were not screened, and infants identified through other hearing screening programs.

RESULTS

30 eligible reports from 14 populations with 7,325,138 infants screened through UNHS from 1616 non-duplicate references were included. UNHS results in a lower age of identification, amplification, and the initiation of early intervention services and better language/literacy development. Better speech perception/production were shown in younger, but not in older, children with early identification after UNHS. No significant findings were found for behavior problems and quality of life. UNHS was found to be cost-effective in terms of savings to society. In addition, no significant parental harm was noted as a result of UNHS.

CONCLUSIONS

In highly developed countries, significantly better outcomes were found for children identified early through UNHS programs. Early language development predicts later literacy and language development.

Bilateral Permanent Childhood Hearing Loss and Health-Related Quality of Life in Adolescence

Little is known about the impact of bilateral permanent childhood hearing loss (PCHL) on health-related quality of life (HRQoL). The objective of this study was to describe preference-based and non-preference based HRQoL outcomes in adolescence, from both self and proxy perspectives, amongst participants of the Hearing Outcomes Project. The Health Utilities Index Marks II (HUI2) and III (HUI3) and the PedsQLTM Version 4.0 Generic Core Scales were used to measure HRQoL based on self and parent proxy reports in 114 adolescents aged 13-19 years, 76 with bilateral PCHL and 38 with normal hearing, recruited from a population sample that was followed up from birth to adolescence. Descriptive statistics and multivariable analyses were used to estimate the relationship between severity of PCHL and HRQoL outcomes. PCHL was associated with decrements in mean multi-attribute utility score that varied between 0.078 and 0.148 for the HUI2 (p = 0.001) and between 0.205 and 0.315 for the HUI3 (p < 0.001), dependent upon the national tariff set applied and respondent group. Multivariable analyses revealed that, after controlling for clinical and sociodemographic covariates, mean HUI3 multi-attribute utility scores were significantly lower in adolescents with moderately severe, severe and profound hearing loss than in adolescents with normal hearing. Significant differences in physical functioning, social functioning, psychosocial functioning and total PedsQLTM scores were only observed when assessments by parents were relied upon, but these dissipated in the multivariable analyses. Bilateral PCHL is associated with poorer HRQoL outcomes in adolescence. Further studies conducted are needed to understand the trajectory and underpinning mechanisms of HRQoL outcomes following PCHL.

Impact of communication modality on caregiver ratings for deaf and hard of hearing children

PURPOSE

Literature on children who are deaf or hard of hearing (DHH) suggests overall increased rates of difficulties in emotional/behavioral and adaptive functioning. However, limitations of this literature include the failure to integrate issues unique to the experience of children who are DHH, such as home and school communication modalities and the consistency of modalities across settings.

METHOD

This study examined de-identified data from a clinical database. Data included caregiver ratings of emotional/behavioral and adaptive functioning in a diverse sample of clinically referred children who are DHH (N = 177). Caregivers also reported home and school communication modalities (e.g., match, partial match, different modalities). We examined mean score differences between our sample and normative samples and compared functioning across subgroups of children with various home-school communication modality combinations.

RESULTS

Consistent with the literature, we found overall increased rates of emotional/behavioral and adaptive functioning concerns on parent rating scales. Emotional/behavioral concerns did not differ among children with spoken language match, sign language match, or partial match communication modalities combinations. Within adaptive functioning, communication and functional academics were significantly lower among children with partial match home-school communication modalities. Adaptive functioning did not differ between spoken language match and sign language match groups.

CONCLUSIONS

Our findings suggest possible benefits to adaptive functioning among children who are DHH when home and school communication modalities match, regardless of which modality is used.

Developmental Outcomes in Early-Identified Children Who Are Hard of Hearing at 2 to 3 Years of Age

OBJECTIVES

This study examined the psychosocial, adaptive behavior, and language outcomes of young children who are hard of hearing (HH) without additional disabilities or neurocognitive impairments. Relations between early developmental outcomes and child and parent demographic variables, and parenting stress and self-efficacy were also explored.

DESIGN

Participants were 39 children with early identified, permanent mild to severe hearing loss, between the ages of 2 and 3 years, and a comparison group of 47 children with normal hearing (NH). Developmental outcomes were measured using clinician-administered standardized tests and parent-completed behavior rating instruments specific to language, psychosocial functioning, and adaptive behavior. Mothers completed self-report measures that assess parenting stress and maternal self-efficacy.

RESULTS

The children who are HH were similar to the children with NH in terms of their psychosocial functioning and adaptive behavior, with the exception of their socialization skills. As a group, the children who are HH performed significantly worse than their peers with NH on all measures of language ability. Among the children who are HH, maternal self-efficacy showed a strong positive correlation with adaptive behavior outcomes; however, it failed to contribute unique variance above that explained by language ability and gender. Maternal self-efficacy was also significantly correlated with better psychosocial outcomes, but only parenting stress proved to be a significant predictor of child behavioral problems once other variables considered were in the model.

CONCLUSIONS

Early-identified young children who are HH can demonstrate age-appropriate development in multiple domains, including language, psychosocial, and adaptive behavior. However, mild to severe hearing loss places young children with no additional disabilities or neurocognitive impairments at risk for language delays. Although the children who are HH demonstrated no more emotional or behavioral problems than their same-age peers with NH, results suggest that language delays increase their vulnerability for delays in various aspects of social competence.

A Technology-Assisted Language Intervention for Children Who Are Deaf or Hard of Hearing: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

Children who are deaf or hard of hearing (DHH) often have persistent language delays despite early identification and interventions. The technology-assisted language intervention (TALI), which incorporates augmentative and alternative communication technology into a speech-language therapy model, was designed to support language learning. The study objective was to evaluate the impact of the TALI on spoken language outcomes in DHH children.

METHODS

Children aged 3 to 12 years with mild to profound bilateral hearing loss were enrolled in a single-site randomized controlled trial. Children were randomly assigned to receive the TALI or treatment as usual (TAU) (with no change in current care) and were followed for 24 weeks. Primary outcomes included spoken language measures elicited from language samples. Secondary outcomes included standardized assessments. Intention-to-treat analyses were used.

RESULTS

Analyses focused on 41 children randomly assigned to TALI (n = 21) or TAU (n = 20). Among all participants, mean age was 6.3 years (SD 2.5). Over 24 weeks, children in the TALI group, compared with those in the TAU group, had significantly greater increases in the length of phrases they used to express themselves (β = .91 vs .15, respectively; P< .0001). Similar findings were seen with conversational turn-taking and number of different words spoken.

CONCLUSIONS

Providing visual supports for language concepts that are typically challenging for DHH children to acquire allowed children to process and comprehend spoken language more fully. Such strategies can mitigate persistent language delays with the goal of improving lifelong outcomes and independence across settings.

Enhancing language in children who are deaf/hard-of-hearing using augmentative and alternative communication technology strategies

BACKGROUND

Despite early identification and intervention, many children who are deaf/hard of hearing (D/HH) demonstrate significant gaps in language development which can directly impact social interactions.

AIMS

The objective of this pilot study was to determine whether integrating augmentative and alternative communication (AAC) core word language strategies into a speech-language therapy program for young children who are D/HH improves spoken language outcomes.

METHODS

Eleven young children, median age 5 years 7 months (range 3y;11 m to 10y;8 m) with bilateral hearing loss were enrolled in a single-case experimental design and completed a 24-week intervention that incorporated high-tech AAC strategies into a traditional speech-language therapy model (technology-assisted language intervention or TALI). The goal of the TALI was to improve spoken language development in children who were D/HH. Language samples were collected throughout the study and pragmatic language was assessed pre and post intervention.

RESULTS

At the end of 24 weeks, children demonstrated a significant increase in their mean length of utterance, number of words spoken, and mean turn length according to language samples. Children also made gains in their pragmatic skills pre to post intervention.

CONCLUSIONS

Results of this study suggest that using AAC core word language strategies delivered via iPad technology may support continued and rapid spoken language skill growth among young school-age children who are D/HH. By leveraging AAC technology, we are pioneering a structured and dynamic approach to language learning, building an effective foundation for concepts and grammar for children who are D/HH.

Assessment and Treatment of Behavioral Disorders in Children with Hearing Loss: A Systematic Review

OBJECTIVE

There is evidence that children who are deaf and hard of hearing (DHH) have a higher incidence of behavioral disorders. Assessment of behavioral health in this population is often complicated by language developmental delays, which may result in unrecognized and untreated behavioral problems. The purpose of this study is to assess the association of behavioral disorders among children who are DHH and to explore behavioral interventions for children in this population.

DATA SOURCES

PubMed, CINALH, PsychINFO, and Web of Science.

REVIEW METHODS

Search terms included the following: problem behavior, child behavior disorders/diagnosis, child behavior disorders/psychology coupled with hearing loss, cochlear implants, hearing aids, or deafness. Studies from the last 30 years (1985-2016) were included. The articles were reviewed independently by 3 reviewers.

RESULTS

Thirty-six articles met criteria. There was an association between internalizing behaviors and hearing loss among children, which may persist after cochlear implantation. These problems may be more pronounced for children with additional disabilities. Conduct and hyperactivity disorders as well as emotional and executive function problems among children who are DHH may be related to poor language development. There was limited evidence regarding interventions to address the behavioral disorders of DHH children.

CONCLUSIONS

There is a significant body of evidence demonstrating behavioral problems among DHH children but a lack of clear understanding of the mechanisms involved. There is limited evidence on interventions to address the behavioral problems of DHH children. Future research is warranted to mitigate the long-term effects of disruptive behavior among these children.

Assessment of Behavioral Problems in Children With Hearing Loss

OBJECTIVE

To compare the prevalence of disruptive behavior problems between preschool-aged children with hearing loss and normal hearing.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary academic center.

PATIENTS

Caregivers of children (2-5 yr old) with normal hearing (NH) (n = 39), hearing loss using hearing aid(s) (HA) (n = 29), or cochlear implant(s) (CI) (n = 21).

INTERVENTION(S)

Demographic information and a mental health history were obtained. Child behavior and language development were assessed.

MAIN OUTCOME MEASURE(S)

The Young Child-Diagnostic Interview Schedule for Children-IV and the MacArthur-Bates Communication Development Inventory III.

RESULTS

Distributions of race, socioeconomic status, insurance status, and parental home situation (single versus two parent family) were similar across all groups. Parents of children with hearing loss were significantly more likely to report behavior problems (HA = 41%, CI = 38%) than parents of NH children (10%; p = 0.002). Children with hearing loss were significantly more likely to meet diagnostic criteria for oppositional defiant disorder (HA = 48%, CI = 48%) than NH children (23%; p = 0.02). More NH children (8%) than hearing impaired children (0%) had accessed mental health services (p = 0.08). NH children were found to have more advanced language development than hearing-impaired children (p < 0.01), but controlling for Communication Development Inventory III percentiles, the observed behavioral differences remained.

CONCLUSION

Controlling for language development, children with hearing loss have higher prevalence of and impairment from disruptive behaviors than their NH peers. These children are less likely to receive appropriate behavioral interventions. Further research is warranted to investigate the impact of disruptive behaviors on speech and hearing rehabilitation. Methods to improve access to effective behavioral interventions in this population are needed.

Psychosocial development of 5-year-old children with hearing loss: Risks and protective factors

OBJECTIVE

The aims of this paper were to report on the global psychosocial functioning of 5-year-old DHH children and examine the risk and protective factors that predict outcomes.

DESIGN

A cross-sectional analysis of data collected from a prospective, population-based longitudinal study.

STUDY SAMPLE

Parents/caregivers of 356 children completed questionnaires on psychosocial development (CDI, SDQ), functional communication (PEACH) and demographic information. Children completed standardized assessments of non-verbal cognitive ability (WNV) and language (PLS-4).

RESULTS

On average, global psychosocial functioning was within the range of typically developing children; however, variability was high and 12% of children had scores that were more than 2 SDs below the norm. Non-verbal cognitive ability, presence of additional disabilities, language and functional communication significantly predicted outcomes. In contrast, type of hearing device, severity of hearing loss and age at intervention did not.

CONCLUSION

The global psychosocial functioning of this cohort of 5-year-old DHH children fell within the range of typically developing children. The findings suggest that spoken language ability and functional communication skills are vital for healthy psychosocial development.

Psychosocial Development in 5-Year-Old Children With Hearing Loss Using Hearing Aids or Cochlear Implants

This article reports on the psychosocial development and factors influencing outcomes of 5-year-old children with cochlear implants (CIs) or hearing aids (HAs). It further examines differences between children with CIs and HAs with similar levels of hearing loss. Data were collected as part of the Longitudinal Outcomes of Children with Hearing Impairment study-a prospective, population-based study. Parents/caregivers of children completed the Strengths and Difficulties Questionnaire ( n = 333), the Social Skills subscale from the Child Development Inventory ( n = 317), and questionnaires on functional auditory behavior (Parents' Evaluation of Aural/oral performance of Children), and demographics. Children completed assessments of nonverbal cognitive ability (Wechsler Non-verbal Scale of Ability) and language (Preschool Language Scale - fourth edition). On average, parent-rated Strengths and Difficulties Questionnaire scores on emotional or behavioral difficulties were within 1 SD of the normative mean; however, Child Development Inventory scores on social skills were more than 1 SD below the norm. Children with severe-to-profound hearing losses using HAs had significantly more behavioral problems than children with CIs. Regression analyses showed that non-verbal cognitive ability, language, and functional auditory behavior were significantly associated with psychosocial outcomes for children with HAs, whereas outcomes for children with CIs were associated with functional auditory behavior and the presence of additional disabilities. Age at hearing intervention, severity of hearing loss, and communication mode were not associated with outcomes. The results suggest that even children who develop good language ability with the help of a HA or CI may have psychosocial problems if they exhibit difficulties with listening and communicating in everyday environments. The findings have implications for developing interventions for young children with hearing loss.

Language and reading comprehension in middle childhood predicts emotional and behaviour difficulties in adolescence for those with permanent childhood hearing loss

BACKGROUND

Permanent childhood hearing loss (PCHL) is associated with an elevated level of emotional and behaviour difficulties (EBD). In children and adolescents with PCHL, EBD has been found to be linked to language ability in children with PCHL. The present study was designed to test whether childhood language and/or reading comprehension abilities of children with PCHL predict subsequent EBD in adolescence.

METHODS

Language comprehension (LC) and reading comprehension (RC) were measured at ages 6-10 years (Time 1) and 13-20 years (Time 2) in participants with PCHL who preferred to communicate using spoken language (n = 57) and a hearing comparison group (n = 38). EBD was measured at both time points by parent and by teacher ratings on the Strengths and Difficulties Questionnaire.

RESULTS

Within the PCHL group there were negative correlations between EBD scores and concurrent LC and RC scores at Time 1 and at Time 2. Cross-lagged latent variable models fitted to the longitudinal data indicated that the associations between LC, RC and teacher-rated EBD were more likely to arise from the impact of LC and RC on behaviour rather than the other way around.

CONCLUSIONS

In those with PCHL, poor language and reading comprehension in middle childhood increased the risk of emotional and behaviour difficulties at school in the teenage years. The results suggest that effective language and literacy interventions for children with hearing loss may also bring benefits to their mental health.

Societal costs of permanent childhood hearing loss at teen age: a cross-sectional cohort follow-up study of universal newborn hearing screening

OBJECTIVE

To investigate the effects in adolescence of bilateral permanent childhood hearing loss (PCHL) > 40 dB and of exposure to universal newborn hearing screening (UNHS) on societal costs accrued over the preceding 12 months.

DESIGN SETTING PARTICIPANTS

An observational cohort study of a sample of 110 adolescents aged 13-20 years, 73 with PCHL and 37 in a normally hearing comparison group (HCG) closely similar in respect of place and date of birth to those with PCHL, drawn from a 1992-1997 cohort of 157 000 births in Southern England, half of whom had been exposed to a UNHS programme.

INTERVENTION

Birth in periods with and without UNHS.

OUTCOME MEASURES

Resource use and costs in the preceding 12-month period, estimated from interview at a mean age of 16.9 years and review of medical records. Effects on costs were examined in regression models.

RESULTS

Mean total costs for participants with PCHL and the HCG were £15 914 and £5883, respectively (difference £10 031, 95% CI £6460 to £13 603), primarily driven by a difference in educational costs. Compared with the HCG, additional mean costs associated with PCHL of moderate, severe and profound severity were £5916, £6605 and £18 437, respectively. The presence of PCHL and an additional medical condition (AMC) increased costs by £15 385 (95% CI £8532 to £22 238). An increase of one unit in receptive language z-score was associated with £1616 (95% CI £842 to £2389) lower costs. Birth during periods of UNHS was not associated with significantly lower overall costs (difference £3594, 95% CI -£2918 to £10 106).

CONCLUSIONS

The societal cost of PCHL was greater with more severe losses and in the presence of AMC and was lower in children with superior language scores. There was no statistically significant reduction in costs associated with birth in periods with UNHS.

TRIAL REGISTRATION NUMBER

ISRCTN03307358, pre-results.

Emotional and behaviour difficulties in teenagers with permanent childhood hearing loss

OBJECTIVES

It is known that during the middle childhood years those with permanent childhood hearing loss (PCHL) are at increased risk of showing emotional and behaviour difficulties (EBD). It has yet to be established whether this risk continues into the late teenage years. There is a paucity of longitudinal studies on the association between PCHL and EBD.

METHODS

The Strengths and Difficulties Questionnaire (SDQ) was used to measure EBD based on parent, teacher and self-ratings in 76 teenagers with PCHL and 38 in a hearing comparison group (HCG) from a population sample of children that was followed up from birth to adolescence.

RESULTS

On parent-rated SDQ, the PCHL group had significantly higher Total Difficulties score than the HCG (Standardised mean difference (SMD) = +0.39, 95%CI 0.00 to 0.79). Amongst the PCHL group the presence of disabilities other than hearing loss had a substantial impact on the level of parent-rated EBD (SMD = +1.68, 1.04 to 2.33). There was a relationship between receptive language ability and EBD in both the HCG (r = -0.33, 95%CI -0.59 to -0.01) and the PCHI group (r = -0.33, 95%CI -0.53 to -0.02). The effect of PCHL on EBD became non-significant when receptive language was included as a covariate (F = 0.12, df = 1,95, p = 0.729). Early confirmation of hearing loss (i.e. before 9 months of age) did not have a significant effect on EBD scores (SMD = +0.31, 95%CI -0.15 to 0.77).

CONCLUSIONS

PCHL continues to be associated with elevated EBD scores as measured by parent rated SDQ into the late teenage years but the degree of this elevation is less than in childhood and is not apparent on teacher or self-ratings. Poor receptive language ability appeared to account for these elevated EBD scores in the group with PCHL. Particular attention needs to be paid to the mental health of children and adolescents with PCHL that is accompanied by other disabilities and to those with poor receptive language ability. However, the majority of teenagers with PCHL do not show clinically significant elevated levels of EBD.

Technology-assisted language intervention for children who are deaf or hard-of-hearing; a pilot study of augmentative and alternative communication for enhancing language development

PURPOSE

Pilot study to assess the effect of augmentative and alternative communication technology to enhance language development in children who are deaf or hard-of-hearing.

MATERIALS AND METHODS

Five children ages 5-10 years with permanent bilateral hearing loss who were identified with language underperformance participated in an individualized 24-week structured program using the application TouchChat WordPower on iPads^®. Language samples were analyzed for changes in mean length of utterance, vocabulary words and mean turn length. Repeated measures models assessed change over time.

RESULTS

The baseline median mean length of utterance was 2.41 (range 1.09-6.63; mean 2.88) and significantly increased over time (p = 0.002) to a median of 3.68 at final visit (range 1.97-6.81; mean 3.62). At baseline, the median total number of words spoken per language sample was 251 (range 101-458), with 100 (range 36-100) different words spoken. Total words and different words significantly increased over time (β = 26.8 (7.1), p = 0.001 for total words; β = 8.0 (2.7), p = 0.008 for different words). Mean turn length values also slightly increased over time.

CONCLUSIONS

Using augmentative and alternative communication technology on iPads^® shows promise in supporting rapid language growth among elementary school-age children who are deaf or hard-of-hearing with language underperformance.

Predictors of Psychosocial Outcomes in Hard-of-Hearing Preschool Children

Children with hearing loss are at risk for developing psychosocial problems. Children with mild to severe hearing loss are less frequently subject to research, in particular in preschool, and we therefore know less about the risk in this particular group. To address this, we compared psychosocial functioning in thirty-five 4-5-year olds with hearing aids to that of 180 typically hearing children. Parent ratings of psychosocial functioning and social skills, as well as scores of receptive vocabulary, were obtained. Children with hearing loss evidenced more psychosocial problems than hearing agemates. Female gender and early detection of hearing loss predicted better psychosocial functioning among children with hearing loss, whereas vocabulary and degree of hearing loss did not. Early intervention addressing psychosocial functioning is warranted for children with all degrees of hearing loss, including mild and moderate. Gender differences should be investigated in future research.

A pilot program in rural telepsychiatry for deaf and hard of hearing populations

Background

Access to mental health care in deaf communities is limited by cultural considerations, availability of translators, and technological considerations. Telepsychiatry can mitigate the deaf community’s lack of access to care by allowing for deaf individuals in remote communities access to care with facilities that cater to their needs.

Methods

Community Behavioral Health, Arundel Lodge, and Gallaudet University worked in conjunction to test three hypotheses:

1.

Telepsychiatry will be as effective as traditional face-to-face psychotherapy with deaf adults who have chronic mental illness.

2.

Patients living in remote locations will report an improvement in accessibility to mental health services.

3.

Patients who receive telepsychiatry will report a comparable level of satisfaction of services to those receiving traditional services.

The patient sample consisted of 24 participants, 13 women, 11 men. Telepsychiatry sessions were scheduled based on each patient’s individual treatment plan against a control group who saw their providers face to face.

Results

The telepsychiatry and in-person groups were slightly different at baseline. Analysis of the data revealed no significant difference in coping abilities and psychiatric symptoms between those receiving face-to-face psychotherapy and those receiving telepsychiatry.

Interpretation

The quality and outcome of care was equal to in-person for the telepsychiatry in deaf patients. Since telepsychiatry does not compromise the quality of care, it is a good means of reaching out to members of the deaf community that cannot readily access mental health resources that meet their needs.

The impact of universal newborn hearing screening on long-term literacy outcomes: a prospective cohort study

OBJECTIVE

To determine whether the benefits of universal newborn hearing screening (UNHS) seen at age 8 years persist through the second decade.

DESIGN

Prospective cohort study of a population sample of children with permanent childhood hearing impairment (PCHI) followed up for 17 years since birth in periods with (or without) UNHS.

SETTING

Birth cohort of 100 000 in southern England.

PARTICIPANTS

114 teenagers aged 13-19 years, 76 with PCHI and 38 with normal hearing. All had previously their reading assessed aged 6-10 years.

INTERVENTIONS

Birth in periods with and without UNHS; confirmation of PCHI before and after age 9 months.

MAIN OUTCOME MEASURE

Reading comprehension ability. Regression modelling took account of severity of hearing loss, non-verbal ability, maternal education and main language.

RESULTS

Confirmation of PCHI by age 9 months was associated with significantly higher mean z-scores for reading comprehension (adjusted mean difference 1.17, 95% CI 0.36 to 1.97) although birth during periods with UNHS was not (adjusted mean difference 0.15, 95% CI -0.75 to 1.06). The gap between the reading comprehension z-scores of teenagers with early compared with late confirmed PCHI had widened at an adjusted mean rate of 0.06 per year (95% CI -0.02 to 0.13) during the 9.2-year mean interval since the previous assessment.

CONCLUSIONS

The benefit to reading comprehension of confirmation of PCHI by age 9 months increases during the teenage years. This strengthens the case for UNHS programmes that lead to early confirmation of permanent hearing loss.

TRIAL REGISTRATION NUMBER

ISRCTN03307358.

Early identification: Language skills and social functioning in deaf and hard of hearing preschool children

OBJECTIVE

Permanent childhood hearing impairment often results in speech and language problems that are already apparent in early childhood. Past studies show a clear link between language skills and the child's social-emotional functioning. The aim of this study was to examine the level of language and communication skills after the introduction of early identification services and their relation with social functioning and behavioral problems in deaf and hard of hearing children.

STUDY DESIGN

Nationwide cross-sectional observation of a cohort of 85 early identified deaf and hard of hearing preschool children (aged 30-66 months).

METHODS

Parents reported on their child's communicative abilities (MacArthur-Bates Communicative Development Inventory III), social functioning and appearance of behavioral problems (Strengths and Difficulties Questionnaire). Receptive and expressive language skills were measured using the Reynell Developmental Language Scale and the Schlichting Expressive Language Test, derived from the child's medical records.

RESULTS

Language and communicative abilities of early identified deaf and hard of hearing children are not on a par with hearing peers. Compared to normative scores from hearing children, parents of deaf and hard of hearing children reported lower social functioning and more behavioral problems. Higher communicative abilities were related to better social functioning and less behavioral problems. No relation was found between the degree of hearing loss, age at amplification, uni- or bilateral amplification, mode of communication and social functioning and behavioral problems.

CONCLUSION

These results suggest that improving the communicative abilities of deaf and hard of hearing children could improve their social-emotional functioning.

Emotional and behavioural difficulties in children and adolescents with hearing impairment: a systematic review and meta-analysis

The aim of this study is to estimate the extent to which children and adolescents with hearing impairment (HI) show higher rates of emotional and behavioural difficulties compared to normally hearing children. Studies of emotional and behavioural difficulties in children and adolescents were traced from computerized systematic searches supplemented, where appropriate, by studies referenced in previous narrative reviews. Effect sizes (Hedges' g) were calculated for all studies. Meta-analyses were conducted on the weighted effect sizes obtained for studies adopting the Strength and Difficulties Questionnaire (SDQ) and on the unweighted effect sizes for non-SDQ studies. 33 non-SDQ studies were identified in which emotional and behavioural difficulties in children with HI could be compared to normally hearing children. The unweighted average g for these studies was 0.36. The meta-analysis of the 12 SDQ studies gave estimated effect sizes of 0.23 (95% CI 0.07, 0.40), 0.34 (95% CI 0.19, 0.49) and -0.01 (95% CI -0.32, 0.13) for Parent, Teacher and Self-ratings of Total Difficulties, respectively. The SDQ sub-scale showing consistent differences across raters between groups with HI and those with normal hearing was Peer Problems. Children and adolescents with HI have scores on emotional and behavioural difficulties measures about a quarter to a third of a standard deviation higher than hearing children. Children and adolescents with HI are in need of support to help their social relationships particularly with their peers.

A test protocol for assessing the hearing status of students with special needs

OBJECTIVES

Individuals with disabilities are often reported to have a high prevalence of undetected hearing disorders/loss, but there is no standardized hearing test protocol for this population. The purposes of this study were (1) to examine the hearing status of students with special needs in Taiwan, and (2) to investigate the use of an on-site hearing test protocol that would adequately detect hearing problems in this population and reduce unnecessary referrals for off-site follow-up services.

METHODS

A total of 238 students enrolled in two schools for special education and one habilitation center participated in the study. Most students had intellectual disabilities and some also had additional syndromes or disorders. A hearing screening protocol including otoscopy, tympanometry, and distortion product otoacoustic emissions was administered to examine students' outer, middle, and inner ear functions, respectively. Pure tone tests were then administered as an on-site follow-up for those who failed or could not be tested using the screening protocol.

RESULTS

Only 32.4% of students passed. When administered alone, the referral rate of otoscopy, tympanometry, and otoacoustic emissions were 38.7%, 46.0%, and 48.5%, respectively. The integration of these subtests revealed 52.1% of students needed follow-up services, 11.8% could not be tested, 2.5% had documented hearing loss, and 1.3% needed to be monitored because of negative middle ear pressure. The inclusion of pure tone audiometry increased the passing rate by 9.9% and provided information on hearing sensitivity for an additional 8.6% of students.

CONCLUSION

Hearing assessments and regular hearing screening should be provided as an integral part of health care services for individuals with special needs because of high occurrences of excessive cerumen, middle ear dysfunction, and sensorineural hearing loss. The training of care-givers and teachers of students with special needs is encouraged so that they can help identify hearing problems and reduce the negative impact of hearing disorders and hearing loss. The screening protocol needs to include subtests that examine the status of different parts of their auditory system. The addition of pure tone audiometry as an on-site follow-up tool reduced the rate of off-site referrals and provided more information on hearing sensitivity.

Diagnostic yield of computed tomography scan for pediatric hearing loss: a systematic review

BACKGROUND

Computed tomography (CT) has been used in the assessment of pediatric hearing loss, but concern regarding radiation risk and increased utilization of magnetic resonance imaging (MRI) have prompted us toward a more quantitative and sophisticated understanding of CT's potential diagnostic yield.

OBJECTIVE

To perform a systematic review to analyze the diagnostic yield of CT for pediatric hearing loss, including subgroup evaluation according to impairment severity and laterality, as well as the specific findings of enlarged vestibular aqueduct and narrow cochlear nerve canal.

DATA SOURCES

PubMed, EMBASE, and the Cochrane Library were assessed from the date of their inception to December 2013. In addition, manual searches of bibliographies were performed and topic experts were contacted.

REVIEW METHODS

Data from studies describing the use of CT in the diagnostic evaluation of pediatric patients with hearing loss of unknown etiology were evaluated, according to a priori inclusion/exclusion criteria. Two independent evaluators corroborated the extracted data. Heterogeneity was evaluated according to the I(2) statistic.

RESULTS

In 50 criteria-meeting studies, the overall diagnostic yield of CT ranged from 7% to 74%, with the strongest and aggregate data demonstrating a point estimate of 30%. This estimate corresponded to a number needed to image of 4 (range, 2-15). The most commonly identified findings were enlarged vestibular aqueduct and cochlear anomalies. The largest studies showed a 4% to 7% yield for narrow cochlear nerve canal.

CONCLUSION

These data, along with similar analyses of radiation risk and risks/benefits of sedated MRI, may be used to help guide the choice of diagnostic imaging.

Functional communication of children who are deaf or hard-of-hearing

OBJECTIVE

The primary aim of this study was to investigate the relationship between language levels and communication and social function skills in young children who are deaf/hard-of-hearing.

METHOD

A cross-sectional design was used with participants sampled predominately from a single clinic setting. Children between 3 and 6 years of age with permanent bilateral hearing loss were enrolled in the study. All children received the Preschool Language Scales-Fifth Edition language assessment and a neurocognitive assessment using the Leiter International Performance Scale-Revised at the study visit. Communication and social function skills were measured using the Vineland Adaptive Behavior Scales-Second Edition (VABS-II; mean 100 ± 15) and the Pediatric Evaluation of Disability Inventory (PEDI; mean 50 ± 10).

RESULTS

Analysis included 65 children with mild to profound bilateral hearing loss (mean age 56.8 months, SD ± 14.1); 52% had hearing loss in the mild to moderate range. The mean nonverbal intelligence quotient (IQ) was 95.7 (±18.8), the mean receptive language standard score was 83.7 (±18.6), and mean expressive language standard score was 83.0 (±18.5). The mean VABS-II communication standard score was 89.1 (±17.5), and the mean PEDI social function score was 39.6 (±15.3). Both nonverbal IQ and receptive language relative to nonverbal IQ (the ratio of language to IQ) were significantly associated with communication and social functioning, explaining more than 50% of the variance in communication function scores. Children with language commensurate with their IQ had significantly higher communication and social function scores than children with language significantly lower than IQ. This finding was consistent across different levels of IQ and independent of degree of hearing loss.

CONCLUSION

Even with early identification and intervention, hearing loss continues to have a life-long impact on functioning. It is important to identify when language levels are not meeting a child's capabilities in order to intervene most effectively.

Parent–Child Interaction Therapy With a Deaf and Hard of Hearing Family

Deaf and hard of hearing (DHH) children are an exceptional needs population with unique mental health concerns requiring specialized intervention. However, psychological interventions aimed at treating these children are limited. Parent–Child Interaction Therapy (PCIT) is an empirically established therapeutic modality for the treatment of children with behavioral and emotional difficulties. This case study describes how PCIT was adapted to effectively intervene in assisting a deaf mother improve parent–child communication, bonding, and her hard-of-hearing son’s behavior. Readers will learn how PCIT was adapted and implemented with a DHH family, including the use of sign language interpreters within the model, translating PCIT behavioral coaching to American Sign Language, and an overall broadened understanding of mental health treatment with the DHH population. The effect of treatment on the child and parent who participated is also discussed.

Aetiology of congenital hearing loss: a cohort review of 569 subjects

OBJECTIVE

Newborn hearing screening was implemented in Flanders about fifteen years ago. The aim of this study was to determine the aetiology of hearing loss detected by the Flemish screening programme.

METHODS

From 1997 to 2011, 569 neonates were referred to our tertiary referral centre after failed neonatal screening with Auditory Brainstem Responses. In case hearing loss (HL) was confirmed, further diagnostic testing was launched. A retrospective chart review was performed analysing the degree of HL, risk factor and aetiology.

RESULTS

Metabolic disorders (0.5%), infectious diseases (35.8%), congenital malformations (6.1%) and genetic abnormalities (19.8%), whether or not syndromic, were retained. In 35% of the subjects no obvious aetiology could be determined in the current study.

CONCLUSION

In contrast to the literature findings, this series shows a genetic syndromic cause in 80% of the genetic bilateral HL cases. On the other hand connexin positive diagnoses were mostly underrepresented in this study, showing the need for better screening.

Peer victimization experienced by children and adolescents who are deaf or hard of hearing

Victimization is a relatively common, yet serious problem, with potentially severe consequences for children's psychosocial and academic functioning. Children who are Deaf or Hard of Hearing (DHH) may be at a higher risk for victimization than hearing children. The aims of the present study were to compare DHH and hearing children on i) self-reported experiences of victimization and ii) associations between victimization, parental- and child variables. In total 188 children (mean age 11;11 years) from the Netherlands and Dutch-speaking part of Belgium participated in the study. No difference between DHH and hearing children were found on general experiences of victimization. However, differences between the groups were found on specific forms of experienced victimization and on the associations between victimization and parental variables. For DHH children, parental sensitivity and parents who challenge their DHH children to become competent in the practical, emotional, cognitive and social domain is associated with them being less victimized. For hearing children at this age these relations were reversed, absent or more complex. Finally, DHH children in special schools were more victimized than DHH children in regular schools. It can be concluded that parents can play an important role in reducing social problems experienced by DHH children and young adolescents.

Mental health of deaf people

Deafness is a heterogeneous condition with far-reaching effects on social, emotional, and cognitive development. Onset before language has been established happens in about seven per 10,000 people. Increased rates of mental health problems are reported in deaf people. Many regard themselves as members of a cultural minority who use sign language. In this Review, we describe discrepancies between a high burden of common mental health disorders and barriers to health care. About a quarter of deaf individuals have additional disabilities and a high probability of complex mental health needs. Research into factors affecting mental health of deaf children shows that early access to effective communication with family members and peers is desirable. Improved access to health and mental health care can be achieved by provision of specialist services with professionals trained to directly communicate with deaf people and with sign-language interpreters.

Nonverbal cognitive development in children with cochlear implants: relationship between the Mullen Scales of Early Learning and later performance on the Leiter International Performance Scales-Revised

Methodologically, longitudinal assessment of cognitive development in young children has proven difficult because few measures span infancy through school age. This matter is further complicated when the child presents with a sensory deficit such as hearing loss. Few measures are validated in this population, and children who are evaluated for cochlear implantation are often reevaluated annually. The authors sought to evaluate the predictive validity of subscales of the Mullen Scales of Early Learning (MSEL) on Leiter International Performance Scales-Revised (LIPS-R) Full-Scale IQ scores. To further elucidate the relationship of these two measures, comparisons were also made with the Vineland Adaptive Behavior Scale-Second Edition (VABS), which provides a measure of adaptive functioning across the life span. Participants included 35 children (14 female, 21 male) who were evaluated both as part of the precandidacy process for cochlear implantation using the MSEL and VABS and following implantation with the LIPS-R and VABS. Hierarchical linear regression revealed that the MSEL Visual Reception subdomain score significantly predicted 52% of the variance in LIPS-R Full-Scale IQ scores at follow-up, F(1, 34) = 35.80, p < .0001, R (2) = .52, β = .72. This result suggests that the Visual Reception subscale offers predictive validity of later LIPS-R Full-Scale IQ scores. The VABS was also significantly correlated with cognitive variables at each time point.

Early detection of hearing impairment in newborns and infants

BACKGROUND

1-2 out of 1000 newborns have markedly impaired hearing.

METHODS

Review of the pertinent literature, which was retrieved with a selective search of the following databases: NHS EED (Economic Evaluation Database), HTA (Health Technology Assessment), DARE (Database of Abstracts of Reviews on Effectiveness), Clinical Trials, CDSR (Cochrane Database of Systematic Reviews), and PubMed.

RESULTS

The current scientific evidence favors universal neonatal hearing screening (UNHS) for the early detection of hearing impairment. UNHS is best performed in two stages: first measurement of otoacoustic emissions and then automated assessment of the brainstem auditory evoked response. To be effective, UNHS programs must have a high coverage rate, high sensitivity and specificity, and proper tracking with a low rate of loss to follow-up. Children with positive screening tests for hearing impairment should undergo confirmatory testing as soon as possible and then receive the appropriate treatment. Early intervention is particularly critical for speech acquisition.

CONCLUSION

The early detection and treatment of hearing impairment in newborns and infants has a beneficial effect on language acquisition.