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Purpose Parent report was compared to judgments made by a trained researcher to determine the utility of the Vocal Development Landmarks Interview (VDLI) for monitoring development of vocal behaviors in very young children. Method Parents of 40 typically developing children, ages 6–21 months, provided full-day naturalistic audio recordings of their children's vocalizations after completing the VDLI. Six 5-min segments of highly voluble periods were selected from each recording and were analyzed, coded, and scored by the researcher. These data were then compared to the parents' VDLI responses. Parent–researcher agreement was examined using two methods and a generalized linear mixed model. Patterns of disagreement were explored descriptively to gain insights regarding potential sources of parent–researcher differences. Finally, developmental patterns in the researcher-observed vocal behaviors were examined as a function of children's age. Results No significant differences in parent–researcher agreement were found for the Canonical and Word subscales of the VDLI; however, significant differences in agreement were found for the Precanonical subscale. Mean percentages of agreement were high overall for both scoring methods evaluated. Additionally, the researcher's categorization and quantification of vocal behaviors for each age group aligned well with developmental trajectories found in the literature. Conclusion Results provide further support for use of parent report to assess early vocal development and use of the VDLI as a clinical measure of vocal development in infants and toddlers ages 6–21 months.

Purpose The aims of this study were to (a) determine if a high-quality adaptation of an audiovisual nonword repetition task can be completed by children with wide-ranging hearing abilities and to (b) examine whether performance on that task is sensitive to child demographics, hearing status, language, working memory, and executive function abilities. Method An audiovisual version of a nonword repetition task was adapted and administered to 100 school-aged children grouped by hearing status: 35 with normal hearing, 22 with mild bilateral hearing loss, 17 with unilateral hearing loss, and 26 cochlear implant users. Participants also completed measures of vocabulary, working memory, and executive function. A generalized linear mixed-effects model was used to analyze performance on the nonword repetition task. Results All children were able to complete the nonword repetition task. Children with unilateral hearing loss and children with cochlear implants repeated nonwords with less accuracy than normal-hearing peers. After adjusting for the influence of vocabulary and working memory, main effects were found for syllable length and hearing status, but no interaction effect was observed. Conclusions The audiovisual nonword repetition task captured individual differences in the performance of children with wide-ranging hearing abilities. The task could act as a useful tool to aid in identifying children with unilateral or mild bilateral hearing loss who have language impairments beyond those imposed by the hearing loss.

OBJECTIVES: There are very limited data regarding the spoken language and academic outcomes of children with mild to severe hearing loss during the elementary school years and the findings of these studies are inconsistent. None of these studies have examined the possible role of aided hearing in these outcomes. This study used a large cohort of children to examine these outcomes and in particular to examine whether aided hearing moderates the effect of hearing loss with regard to these outcomes. DESIGN: The spoken language, reading, writing, and calculation abilities were measured after second and fourth grades in children with mild to severe hearing loss (children who are hard of hearing; CHH, n = 183) and a group of children with normal hearing (CNH, n = 91) after the completion of second and fourth grades. Also, among the CHH who wore hearing aids, aided better-ear speech intelligibility index (BESII) values at the age of school entry were obtained. RESULTS: Oral language abilities of the CHH with mild and moderate hearing loss were similar to the CNH at each grade. Children with moderately-severe hearing loss (better-ear pure tone threshold > 59

Purpose Tracking of infants' progression through early vocal stages supports the identification of children at risk for language delays and guides early intervention for children with disabilities. However, few clinical tools are available to support systematic assessment of infants' early vocal development. This study sought to develop and conduct a preliminary evaluation of the validity of a parent report tool designed for this purpose, the Vocal Development Landmarks Interview (VDLI). Method The participants were caregivers of 160 typically developing 6- to 21-month-old infants. Caregivers participated in the VDLI, which uses audio samples of authentic infant vocalizations to query parents regarding their children's vocal behaviors. The VDLI yields 3 subscale scores (Precanonical, Canonical, and Word) and a total score. Caregivers also completed sections of the Communication and Symbolic Behavior Scales Developmental Profile Caregiver Questionnaire that yielded a speech composite score. Results Cross-sectional analyses showed that the VDLI is sensitive to age and captures the expected developmental trajectories of vocal behaviors. A strong, positive correlation ( r = .93) was found between VDLI total scores and the Communication and Symbolic Behavior Scales Developmental Profile speech composite score, indicating concurrent validity. Subscales were found to be internally consistent. Conclusion Preliminary findings of sensitivity to age, concurrent validity, and internal consistency provide support for the eventual use of the VDLI as a clinical tool for tracking vocal and early verbal milestones. Future research will explore the level of concordance between parent report and researcher observations of child vocal behaviors. Supplemental Material https://doi.org/10.23641/asha.8330003

OBJECTIVES: 1) Identify the etiologies and risk factors of the patient cohort and determine the degree to which they reflected the incidence for children with hearing loss and 2) quantify practice management patterns in three catchment areas of the United States with available centers of excellence in pediatric hearing loss DESIGN: Medical information for 307 children with bilateral, mild to severe hearing loss was examined retrospectively. Children were participants in the Outcomes of Children with Hearing Loss (OCHL) study, a five-year longitudinal study that recruited subjects at three different sites. Children aged 6 months to 7 years at time of OCHL enrollment were participants in this study. Children with cochlear implants, children with severe or profound hearing loss, and children with significant cognitive or motor delays were excluded from the OCHL study and, by extension, from this analysis. Medical information was gathered using medical records and participant intake forms, the latter reflecting a caregiver’s report. A comparison group included 134 children with normal hearing. A chi-square test on two-way tables was used to assess for differences in referral patterns by site for the children who are hard of hearing (CHH). Linear regression was performed on gestational age and birth weight as continuous variables. Risk factors were assessed using t-tests. The alpha value was set at p < 0.05. RESULTS: Neonatal intensive care unit stay, mechanical ventilation, oxygen requirement, aminoglycoside exposure, and family history were correlated with hearing loss. For this study cohort, congenital cytomegalovirus (CMV), strep positivity, bacterial meningitis, extracorporeal membrane oxygenation (ECMO), and loop diuretic exposure were not associated with hearing loss. Less than 50% of children underwent imaging, although 34.2% of those scanned had abnormalities identified. No single imaging modality was preferred. Differences in referral rates were apparent for neurology, radiology, genetics, and ophthalmology. CONCLUSIONS: The OCHL cohort reflects known etiologies of CHH. Despite available guidelines, centers of excellence, and high yield rates for imaging, the medical work-up for children with hearing loss remains inconsistently implemented and widely variable. There remains limited awareness as to what constitutes appropriate medical assessment for CHH.

Purpose To describe factors affecting early intervention (EI) for children who are hard of hearing, we analyzed (a) service setting(s) and the relationship of setting to families' frequency of participation, and (b) provider preparation, caseload composition, and experience in relation to comfort with skills that support spoken language for children who are deaf and hard of hearing (CDHH). Method Participants included 122 EI professionals who completed an online questionnaire annually and 131 parents who participated in annual telephone interviews. Results Most families received EI in the home. Family participation in this setting was significantly higher than in services provided elsewhere. EI professionals were primarily teachers of CDHH or speech-language pathologists. Caseload composition was correlated moderately to strongly with most provider comfort levels. Level of preparation to support spoken language weakly to moderately correlated with provider comfort with 18 specific skills. Conclusions Results suggest family involvement is highest when EI is home-based, which supports the need for EI in the home whenever possible. Access to hands-on experience with this population, reflected in a high percentage of CDHH on providers' current caseloads, contributed to professional comfort. Specialized preparation made a modest contribution to comfort level.

This study contrasted the early literacy outcomes of children who are hard of hearing (CHH) with children with normal hearing (CNH). At age 5, prereading skills of oral language, phonological processing, and print knowledge were examined in CHH (N = 180) and CNH (N = 80). The CHH had poorer oral language and phonological processing abilities than the CNH but comparable knowledge of print. At age 8, measures of word reading, and reading comprehension yielded no differences between CHH (N = 108) and CNH (N = 62) except for reading comprehension for the moderately severe CHH. Reading achievement in CHH was found to exceed predictions based on prereading performance. This resilience was associated with gains in oral language during the early school years.

Objective: Semi-structured interviews were conducted with sequentially implanted bilateral cochlear-implant (biCI) recipients to examine functional aspects of communication that are affected by listening with one versus two CIs. Design: Participants were 15 adult biCI recipients and parents of 30 children (categorized into three groups by age) with biCIs. All CI users had sequential placement of biCIs with at least six months’ experience with the first CI before activation of the second device, and at least three months’ experience with both CIs prior to the interview. The parent/paediatric and adult interviews were all conducted by the same examiner. Electronic transcripts of the interview responses were coded for perceived changes or lack thereof in 23 behaviours following biCI. Extent of reported benefit was quantified for each subject within and across these behaviours and at the group level as a function of age. Results: Most adults and parents of children reported multiple functional changes following biCI use, and changes often translated to enhanced social communication. Nearly all participants were consistent users of biCIs, and were satisfied with their perceived gains in communicating in everyday settings. Most reported ongoing challenges listening in noisy settings. Although many reports on children paralleled those of adults, developmental differences were apparent. Thirteen percent of adults and twenty percent of parents of children in each of the respective groups reported low levels of change. Conclusions: Results suggest that many biCI users experience meaningful functional benefits that may be underestimated by traditional outcome measures. We suggest the need to expand measurement approaches to better quantify the nature of these benefits.

Objectives This study examined the language outcomes of children with mild to severe hearing loss during the preschool years. The longitudinal design was leveraged to test whether language growth trajectories were associated with degree of hearing loss and whether aided hearing influenced language growth in a systematic manner. The study also explored the influence of the timing of hearing aid fitting and extent of use on children's language growth. Finally, the study tested the hypothesis that morphosyntax may be at particular risk due to the demands it places on the processing of fine details in the linguistic input. Design The full cohort of children in this study comprised 290 children who were hard of hearing (CHH) and 112 children with normal hearing who participated in the Outcomes of Children with Hearing Loss (OCHL) study between the ages of 2 and 6 years. CHH had a mean better-ear pure-tone average of 47.66 dB HL (SD = 13.35). All children received a comprehensive battery of language measures at annual intervals, including standardized tests, parent-report measures, and spontaneous and elicited language samples. Principal components analysis supported the use of a single composite language score for each of the age levels (2, 3, 4, 5, and 6 years). Measures of unaided (better-ear pure-tone average, speech intelligibility index) and aided (residualized speech intelligibility index) hearing were collected, along with parent-report measures of daily hearing aid use time. Mixed modeling procedures were applied to examine the rate of change (227 CHH; 94 children with normal hearing) in language ability over time in relation to (1) degree of hearing loss, (2) aided hearing, (3) age of hearing aid fit and duration of use, and (4) daily hearing aid use. Principal components analysis was also employed to examine factor loadings from spontaneous language samples and to test their correspondence with standardized measures. Multiple regression analysis was used to test for differential effects of hearing loss on morphosyntax and lexical development. Results Children with mild to severe hearing loss, on average, showed depressed language levels compared with peers with normal hearing who were matched on age and socioeconomic status. The degree to which CHH fell behind increased with greater severity of hearing loss. The amount of improved audibility with hearing aids was associated with differential rates of language growth; better audibility was associated with faster rates of language growth in the preschool years. Children fit early with hearing aids had better early language achievement than children fit later. However, children who were fit after 18 months of age improved in their language abilities as a function of the duration of hearing aid use. These results suggest that the language learning system remains open to experience provided by improved access to linguistic input. Performance in the domain of morphosyntax was found to be more delayed in CHH than their semantic abilities. Conclusion The data obtained in this study largely support the predictions, suggesting that mild to severe hearing loss places children at risk for delays in language development. Risks are moderated by the provision of early and consistent access to well-fit hearing aids that provide optimized audibility.

Objectives The primary objective of this article was to describe recruitment, data collection, and methods for a longitudinal, multicenter study involving children with bilateral mild to severe hearing loss. The goals of this research program were to characterize the developmental outcomes of children with mild to severe bilateral hearing loss during infancy and the preschool years. Furthermore, the researchers examined how these outcomes were associated with the child's hearing loss and how home background and clinical interventions mediated and moderated these outcomes. Design The participants in this study were children who are hard of hearing (CHH) and children with normal hearing (CNH) who provided comparison data. CHH were eligible for participation if (1) their chronological age was between 6 months and 7 years of age at the time of recruitment, (2) they had a better-ear pure-tone average of 25 to 75 dB HL, (3) they had not received a cochlear implant, (4) they were from homes where English was the primary language, and (5) they did not demonstrate significant cognitive or motor delays. Across the time span of recruitment, 430 parents of potential children with hearing loss made contact with the research group. This resulted in 317 CHH who qualified for enrollment. In addition, 117 CNH qualified for enrollment. An accelerated longitudinal design was used, in which multiple age cohorts were followed long enough to provide overlap. Specifically, children were recruited and enrolled continuously across an age span of 6.5 years and were followed for at least 3 years. This design allowed for tests of time (period) versus cohort age effects that could arise by changes in services and technology over time, yet still allowed for examination of important developmental relationships. Results The distribution of degree of hearing loss for the CHH showed that the majority of CHH had moderate or moderate-to-severe hearing losses, indicating that the sample undersampled children with mild HL. For mothers of both CHH and CNH, the distribution of maternal education level showed that few mothers lacked at least a high school education and a slight majority had completed a bachelor's degree, suggesting that this sample of research volunteers was more advantaged than the United States population. The test battery consisted of a variety of measures concerning participants' hearing and behavioral development. These data were gathered in sessions during which the child was examined by an audiologist and a speech-language examiner. In addition, questionnaires concerning the child's behavior and development were completed by the parents. Conclusion The Outcomes of Children with Hearing Loss study was intended to examine the relationship between variation in hearing ability across children with normal and mild to severe hearing loss and variation in their outcomes across several domains of development. In addition, the research team sought to document important mediators and moderators that act between the hearing loss and the outcomes. Because the study design provided for the examination of outcomes throughout infancy and early childhood, it was necessary to employ a number of different measures of the same construct to accommodate changes in developmental performance across age. This resulted in a large matrix of measures across variable types and developmental levels, as described in this manuscript.

The primary purpose of the epilogue article is to synthesize the key findings from the Outcomes of Children with Hearing Loss (OCHL) study by presenting a set of 10 major conclusions. The conclusion statements provide a concise summary of the main results related to children's auditory and language outcomes and factors identified as moderators of these outcomes. The second section of this article summarizes the primary clinical implications that follow from the OCHL study in relation to three questions: (1) Can we afford to be complacent about the current outcomes of children who are hard of hearing? (2) Which malleable factors can be addressed to promote success through implementation of best practices? and (3) Which nonmalleable factors are consequential and what are their implications for practice? The authors end with some future research directions for the OCHL project.

Objectives This study investigated automatic assessment of vocal development in children with hearing loss compared with children who are typically developing, have language delays, and have autism spectrum disorder. Statistical models are examined for performance in a classification model and to predict age within the four groups of children. Design The vocal analysis system analyzed 1913 whole-day, naturalistic acoustic recordings from 273 toddlers and preschoolers comprising children who were typically developing, hard of hearing, language delayed, or autistic. Results Samples from children who were hard of hearing patterned more similarly to those of typically developing children than to the language delayed or autistic samples. The statistical models were able to classify children from the four groups examined and estimate developmental age based on automated vocal analysis. Conclusions This work shows a broad similarity between children with hearing loss and typically developing children, although children with hearing loss show some delay in their production of speech. Automatic acoustic analysis can now be used to quantitatively compare vocal development in children with and without speech-related disorders. The work may serve to better distinguish among various developmental disorders and ultimately contribute to improved intervention.

Purpose To characterize preschool and school services for children who are hard of hearing (CHH), we described service setting, amount, and configuration and analyzed the relationship between service receipt and student hearing levels and language scores. Characteristics of professionals providing services were described and then used to predict level of comfort with skills supporting listening and spoken language. The amount of provider communication with children's audiologists was also investigated. Method Participants included parents of CHH (preschool n = 174; school n = 155) and professionals (preschool n = 133; school n = 104) who completed interviews and questionnaires as part of a longitudinal study. Children's hearing, speech, and language data were collected from annual testing and analyzed in relation to service data. Results A majority (81%) of preschool-age CHH received services. Children were more likely to be in a preschool for children who are deaf or hard of hearing (CDHH) or exceptional children than a general education preschool. By elementary school, 70% received services, nearly all in general education settings. Sessions averaged twice a week for a total of approximately 90 min. Children who no longer received services performed significantly better on speech/language measures than those who received services, regardless of service setting. Professionals were primarily speech-language pathologists (SLPs) and teachers of CDHH. SLPs reported significantly less comfort with skills involving auditory development and hearing technologies and less frequent communication with the child's audiologists than teachers of CDHH. Overall communication with audiologists was more frequent in the preschool years. Conclusions As preschool-age CHH transition into school, the majority continue to qualify for services. Congruent with national trends, school-age CHH in the Outcomes of Children with Hearing Loss study were most often in general education settings. Without specialized preprofessional or postgraduate training, SLPs and teachers of CDHH did not report comfort with all the skills critical to developing listening and spoken language. This finding supports the need for increased implementation of interprofessional practice among SLPs and teachers of CDHH, as well as audiologists, to best meet the needs unique to this population.

Objectives The purpose of this study was to examine word recognition in children who are hard of hearing (CHH) and children with normal hearing (CNH) in response to time-gated words presented in high- versus low-predictability sentences (HP, LP), where semantic cues were manipulated. Findings inform our understanding of how CHH combine cognitive-linguistic and acoustic-phonetic cues to support spoken word recognition. It was hypothesized that both groups of children would be able to make use of linguistic cues provided by HP sentences to support word recognition. CHH were expected to require greater acoustic information (more gates) than CNH to correctly identify words in the LP condition. In addition, it was hypothesized that error patterns would differ across groups. Design Sixteen CHH with mild to moderate hearing loss and 16 age-matched CNH participated (5 to 12 years). Test stimuli included 15 LP and 15 HP age-appropriate sentences. The final word of each sentence was divided into segments and recombined with the sentence frame to create series of sentences in which the final word was progressively longer by the gated increments. Stimuli were presented monaurally through headphones and children were asked to identify the target word at each successive gate. They also were asked to rate their confidence in their word choice using a five- or three-point scale. For CHH, the signals were processed through a hearing aid simulator. Standardized language measures were used to assess the contribution of linguistic skills. Results Analysis of language measures revealed that the CNH and CHH performed within the average range on language abilities. Both groups correctly recognized a significantly higher percentage of words in the HP condition than in the LP condition. Although CHH performed comparably with CNH in terms of successfully recognizing the majority of words, differences were observed in the amount of acoustic-phonetic information needed to achieve accurate word recognition. CHH needed more gates than CNH to identify words in the LP condition. CNH were significantly lower in rating their confidence in the LP condition than in the HP condition. CHH, however, were not significantly different in confidence between the conditions. Error patterns for incorrect word responses across gates and predictability varied depending on hearing status. Conclusions The results of this study suggest that CHH with age-appropriate language abilities took advantage of context cues in the HP sentences to guide word recognition in a manner similar to CNH. However, in the LP condition, they required more acoustic information (more gates) than CNH for word recognition. Differences in the structure of incorrect word responses and their nomination patterns across gates for CHH compared with their peers with NH suggest variations in how these groups use limited acoustic information to select word candidates.

PurposeSpoken language skills of 3- and 6-year-old children who are hard of hearing (HH) were compared with those of children with normal hearing (NH).MethodLanguage skills were measured via mean length of utterance in words (MLUw) and percent correct use of finite verb morphology in obligatory contexts based on spontaneous conversational samples gathered from 185 children (145 HH, 40 NH). Aided speech intelligibility index (SII), better-ear pure-tone average (BE-PTA), maternal education, and age of amplification were used to predict outcomes within the HH group.ResultsOn average, the HH group had MLUws that were 0.25–0.5 words shorter than the NH group at both ages, and they produced fewer obligatory verb morphemes. After age, aided SII and age of amplification predicted MLUw. Aided SII and BE-PTA were not interchangeable in this analysis. Age followed by either BE-PTA or aided SII best predicted verb morphology use.ConclusionsChildren who are HH lag behind their peers with NH in grammatical aspects of language. Although some children appear to catch up, more than half of the children who are HH fell below the 25th percentile. Continued monitoring of language outcomes is warranted considering that children who are HH are at increased risk for language learning difficulties.

A diverse panel of experts convened in Bad Ischl, Austria, in June of 2012 for the purpose of coming to consensus on essential principles that guide family-centered early intervention with children who are deaf or hard of hearing (D/HH). The consensus panel included parents, deaf professionals, early intervention program leaders, early intervention specialists, and researchers from 10 nations. All participants had expertise in working with families of children who are D/HH, and focus was placed on identifying family-centered practice principles that are specific to partnering with these families. Panel members reported that the implementation of family-centered principles was uneven or inconsistent in their respective nations. During the consensus meeting, they identified 10 agreed-upon foundational principles. Following the conference, they worked to refine the principles and to develop a document that described the principles themselves, related program and provider behaviors, and evidence supporting their use (drawing upon studies from multiple disciplines and nations). The goal of this effort was to promote widespread implementation of validated, evidence-based principles for family-centered early intervention with children who are deaf and hard of hearing and their families.

Purpose This study investigated predictors of hearing aid (HA) use time for children with mild-to-severe hearing loss (HL). Barriers to consistent HA use and reliability of parent report measures were also examined. Method Participants included parents of 272 children with HL. Parents estimated the amount of time the child used HAs daily. Regression analysis examined the relationships among independent variables and HA use time. To determine parental accuracy of HA use time, datalogging from the HAs was compared to the parents' estimates. Results Longer HA use related to older age, poorer hearing, and higher maternal education. Parental consistency ratings revealed similar findings—younger children and children with milder HL wore HAs less consistently than older children and children with more severe HL. Parents' estimates and datalogging were significantly correlated; however, results suggested that parents overestimate the amount of time their children wear their HAs. Conclusion Certain variables were significantly related to the amount of time children wore their HAs. Consistency rating scales provided insight into circumstances that were challenging for families. Use of both parent reports and datalogging may allow clinicians and researchers to obtain a general estimate of HA use time.

OBJECTIVES Amplification is a core component of early intervention for children who are hard of hearing, but hearing aids (HAs) have unique effects that may be independent from other components of the early intervention process, such as caregiver training or speech and language intervention. The specific effects of amplification are rarely described in studies of developmental outcomes. The primary purpose of this article is to quantify aided speech audibility during the early childhood years and examine the factors that influence audibility with amplification for children in the Outcomes of Children with Hearing Loss study. DESIGN Participants were 288 children with permanent hearing loss who were followed as part of the Outcomes of Children with Hearing Loss study. All of the children in this analysis had bilateral hearing loss and wore air-conduction behind-the-ear HAs. At every study visit, hearing thresholds were measured using developmentally appropriate behavioral methods. Data were obtained for a total of 1043 audiometric evaluations across all subjects for the first four study visits. In addition, the aided audibility of speech through the HA was assessed using probe microphone measures. Hearing thresholds and aided audibility were analyzed. Repeated-measures analyses of variance were conducted to determine whether patterns of thresholds and aided audibility were significantly different between ears (left versus right) or across the first four study visits. Furthermore, a cluster analysis was performed based on the aided audibility at entry into the study, aided audibility at the child's final visit, and change in aided audibility between these two intervals to determine whether there were different patterns of longitudinal aided audibility within the sample. RESULTS Eighty-four percent of children in the study had stable audiometric thresholds during the study, defined as threshold changes

The landscape of service provision for young children with hearing loss has shifted in recent years as a result of newborn hearing screening and the early provision of interventions, including hearing technologies. It is expected that early service provision will minimize or prevent linguistic delays that typically accompany untreated permanent childhood hearing loss. The post-newborn hearing screening era has seen a resurgence of interest in empirically examining the outcomes of children with hearing loss to determine if service innovations have resulted in expected improvements in children's functioning. The Outcomes of Children with Hearing Loss (OCHL) project was among these recent research efforts, and this introductory article provides background in the form of literature review and theoretical discussion to support the goals of the study. The Outcomes of Children with Hearing Loss project was designed to examine the language and auditory outcomes of infants and preschool-age children with permanent, bilateral, mild-to-severe hearing loss, and to identify factors that moderate the relationship between hearing loss and longitudinal outcomes. The authors propose that children who are hard of hearing experience limitations in access to linguistic input, which lead to a decrease in uptake of language exposure and an overall reduction in linguistic experience. The authors explore this hypothesis in relation to three primary factors that are proposed to influence children's access to linguistic input: aided audibility, duration and consistency of hearing aid use, and characteristics of caregiver input.

In this brief afterword, we discuss the challenges and lessons learned in the process of implementing a multi-site, longitudinal study. Some of the lessons learned by the research team are shared regarding research design and analysis, strategies implemented to reduce threats to validity, and techniques used to promote teamwork and collaboration across sites.

Automated analyses of full-day recordings were used to determine whether young children who are hard-of-hearing (HH) received similar levels of exposure to adult words and conversational interactions as age-matched peers with normal-hearing (NH). Differences in adult input between children in this study and in a normative database were considered. Finally, factors were examined that may have contributed to individual differences in the input characteristics of families. Results indicated that the NH and HH groups were exposed to similar numbers of adult words and conversational turns. However, both the NH and HH groups were exposed to more adult words and engaged in more conversational turns than the NH children in the normative sample. Considering only the HH group, both quantity of adult words and conversational exchanges were correlated with children’s auditory characteristics. Children’s receptive language ability was correlated with conversational exchanges but not with adult word counts. Children’s exposure to language during the early language-learning period plays a critical role in shaping their linguistic development. Most children spend the majority of this period being cared for by their family members (Belsky et al., 2007), and parents are key con

A primary goal of early intervention is to prevent or minimize communication delays that typically accompany childhood hearing loss. This article describes recent insights about language development that are based on studies of this new generation of early-identified infants with hearing loss. Also discussed are persistent challenges that need to be addressed to optimize the promise of early identification. Three main premises are addressed, including: (1) early intervention provides developmental advantages not just for the child, but for the family; (2) recent developmental findings provide audiologists with benchmarks for monitoring outcomes; and (3) language learning is supported by auditory experience, which is influenced by consistent device use and access to incidental learning. The first premise supports the need to broaden the ways we characterize the benefits of early identification to include family outcomes. The second premise includes a summary of vocal and verbal landmarks that are helpful in determining progress and identifying children who may be at risk. The final premise explores issues that may impact language access, along with strategies to address them.

Studies of language development in young children with mild-moderate sensorineural hearing loss (MMHL) are relatively rare. Existing studies suggest that some children with MMHL are at risk for language delays, particularly in areas such as phonology, morphology, and advanced vocabulary and syntax production (Borg, Edquist, Reinholdson, et al., 2007; Delage & Tuller, 2007; Elfenbein, Hardin-Jones, & Davis, 1994; Kennedy, McCann, Campbell, et al., 2006; Kiese-Himmel & Reeh, 2006; Wake, Hughes, Poulakis, et al., 2004). Most studies in the extant literature involve children whose hearing losses were identified late compared to contemporary standards (see Moeller, Tomblin, Yoshinaga-Itano, et al., 2007 for a review). These children presumably experienced varying periods of reduced or degraded input prior to the fitting of amplification, and this factor exerts influence on outcomes (Norbury, Bishop, & Briscoe, 2001). To date, the impact of these differences in early auditory experience on language development is not well understood. Prospective longitudinal analyses may be helpful in understanding how delayed access to amplification affects language, and whether children with MMHL may “recover” from initial delays once interventions are provided. Such questions remain relevant in the era of newborn hearing screening, because findings may provide indirect support for early identification and guide the management of children with MMHL who continue to be identified late. There is some disagreement in the literature about the persistence of language delays associated with MMHL. Some suggest that even mild hearing loss places a child at risk for lasting language delays (Davis, Elfenbein, Schum, & Bentler, 1986), while others conclude that peripheral hearing impairment is ‘compensated for’ in many children with MMHL (Borg, et al., 2007). Delage and Tuller (2007) reported that 19 adolescents with MMHL were found to be at greater risk for language impairment than peers with NH, indicating that language delays do not necessarily normalize with age in this group. There also is disagreement about the prevalence of co-morbid language disabilities in this group of children (Borg, et al., 2007; Delage & Tuller, 2007; Gilbertson & Kamhi, 1995), but there is a consensus that their existence influences outcome. The overall pattern of equivocal results may be related to differences in characteristics of the samples (e.g., variation in periods without amplification, presence of co-morbid conditions) and measurement factors (e.g., ages examined, constructs measured, and sensitivity of measurement tools). A point of agreement across studies is the wide individual variation in outcomes, which speaks to the need for a better understanding of variables that influence outcomes over time in children with MMHL. Selected aspects of speech and language may be particularly susceptible to the presence of MMHL and delayed access to amplification. Delage and Tuller (2007) drew upon the literature on critical periods (e.g., Newport, Bavelier & Neville, 2001 cited in Delage & Tuller, 2007) to suggest that formal aspects of language (phonology and morphosyntax) are more vulnerable in the face of protracted language development than vocabulary or semantics. Children with late-identified hearing loss spend a portion of critical language acquisition periods with degraded or partial language input, which may differentially affect phonology and morphology. There are consistent reports in the literature of delays in phonological skills (Elfenbein, et al., 1994; see Eisenberg, 2007 for a review) and verb morphology in this population of children (Delage & Tuller, 2007; Elfenbein, et al., 1994; McGuckian & Henry, 2007; Norbury, et al., 2001), which may lend support to the notion that these areas are vulnerable. Elfenbein and colleagues (1994) conducted a cross-sectional study of 40 students with mild to severe HL that included articulation measures. The common persistent errors observed in the speech of the children involved the production of fricatives and affricates. Delays in mastery of verb tense marking also have been identified in children with MMHL (Delage & Tuller, 2007; Elfenbein, et al., 1994; McGuckian & Henry, 2007), but it is unclear if such delays resolve with age. Delage & Tuller (2007) identified disorders in phonology and morphosyntax in half of their French-speaking adolescents (n = 19) with MMHL, suggesting persistent difficulties in these susceptible areas. Norbury, et al. (2001) found that children with mild-moderate HL (ages 5–10; n = 19) performed similarly to children with NH on verb morphology tasks. However the youngest children with HL in their sample (n = 6) demonstrated difficulty with third person singular –s and past tense markers. The average age of hearing aid fitting for this sample was 48.2 months. The authors concluded that “disrupted auditory input during the time of normal language acquisition may delay the development of a number of different linguistic skills, including verb tense marking (p 175).” In addition to atypical early auditory experience, limitations in audibility following intervention may continue to influence the development of both phonology and morphosyntax for children with MMHL. The limited bandwidth of hearing aids is known to affect perception and production of consonants in the fricative class (Moeller, Hoover, Putman, et al., 2007; Stelmachowicz, Pittman, Hoover, & Lewis, 2001, 2002). Children with MMHL (5–13 years of age) demonstrated highly variable perception of –s marking plurality compared to 3–5 year olds with NH (Stelmachowicz, et al., 2002). Because of reduced audibility, particularly in contexts of noise and reverberation, children with MMHL may receive inconsistent input about obligatory contexts for using morphological endings in English, complicating the process of rule formation. This may be particularly true for verb tense markers like third person singular (She needs help), that often occur in phrase-medial positions of sentences, which can reduce the overall amplitude of final consonants (Song, Sundara, & Demuth, 2009). If this is the case, it is hypothesized that forms like third person singular (/3s) will be more delayed than other tense markers for children with MMHL. The order in which children with MMHL begin to mark for verb tense may hold clues to the contributions of audibility in morphological development. The onset and consistent use of verb tense marking has been studied extensively in children with NH, including both typically developing and those with language impairments. Researchers have been particularly interested in a small group of verb tense markers that form a coherent set in development and are sensitive to the identification of language impairment in children (Leonard, Miller & Gerber, 1999; Rice & Wexler, 1996). They include forms of the following verbs: (1) copula BE (My hat is red), (2) third person singular present tense (/3s - Joey runs), (3) auxiliary verb BE (The girl is jumping), (4) auxiliary DO (Does he like it?), and (5) past tense regular –ed (We walk/ed) (Hadley & Short, 2005). According to Hadley (2006), this group of morphemes is important because they share the role of marking the underlying grammatical feature of tense in sentences, even though they differ in their surface forms. In typical development, tense marking begins between two and one half years of age (Rispoli, Hadley & Holt, 2009), and all of the forms are present by three years for the majority of children with NH (Hadley, 2006; Hadley & Short, 2005; Hadley & Rice, 1996). It is of interest for the current analysis that third person singular (/3s) is among the earliest appearing tense morphemes for children with NH (Hadley, 2006). Delays in use of verb tense marking and use of other morphological markers also may reflect instability in the children’s phonological mastery of fricatives and production of final blends, like /kt/ in walked or /ts/ in cats (Song, et al., 2009). Phonology and morphology are interdependent aspects of development for all children. If both areas are vulnerable for children with late-identified MMHL, a better understanding of their joint influences on language development is needed. The current study is a longitudinal descriptive analysis of selected aspects of phonology and morphosyntactic development in four children with MMHL who were late identified. Although the sample is small, longitudinal studies from the point of identification of this group of children are particularly rare. These cases represent a unique opportunity to address several questions: (1) What are the effects of a period of unaided MMHL on language development (based on measures at or near the point of identification)? This is of particular interest because it is not ethical to conduct a randomized controlled study where children are assigned to treatment and non-treatment groups. (2) What is the developmental order of verb tense marking and does it suggest influences of audibility on morphology? (3) Do early delays resolve with development and intervention, and if errors persist, are they in areas predicted to be vulnerable?

Physicians and other health-care providers should play a central role in helping families of children with permanent hearing loss receive timely and appropriate screening, diagnostic, and early intervention services. Because the technology and procedures for ensuring timely and appropriate services for infants and young children with hearing loss have changed so dramatically over the past 15 years, many health-care providers are not well informed about the best ways to provide effective services. Audiologists can help to ensure that physicians and other health-care providers are better informed about the services needed by infants and young children with hearing loss. This article notes some of the areas where information and support is most needed and suggests resources and strategies for addressing these needs.

Purpose To examine the consistency of hearing aid use by infants. A goal was to identify maternal, child, and situational factors that affected consistency of device use. Method Maternal interviews were conducted using a nonvalidated structured interview (Amplification in Daily Life Questionnaire ) that included 5-point Likert scale items and open-ended questions. Participants were mothers of 7 infants with mild to moderately severe hearing loss who were enrolled in a longitudinal study. Data were collected at 4 intervals (10.5–12, 16.5, 22.5, and 28.5 months old). Results Consistency of amplification use was variable at early ages but improved with age. By age 28.5 months, toddlers used amplification regularly in most settings. Selected daily situations (e.g., in car or outdoors) were more challenging for maintaining device use than contexts where the child was closely monitored. Only 2 families established early, consistent full-time use across all contexts examined. Qualitative results were used to identify familial, developmental, and situational variables that influenced the consistency of infant/toddler device use. Conclusion Families may benefit from audiologic counseling that acknowledges the multifaceted challenges that arise. Audiologists can work in partnership with families to promote consistent device use across a variety of daily situations.

The purpose of this review is to synthesize historical and recent evidence concerning psychosocial development in children with mild to severe hearing impairment. Included are studies of quality of life, social-emotional development, self-concept, and social access. Concerns are raised about sampling issues and limited consistency in measurement strategies used. Interdisciplinary perspectives on social-emotional learning and development are integrated in an effort to identify research gaps and suggest future research needs. The need for prospective studies involving a new generation of children with early access to amplification is stressed.

The purpose of this paper is to provide a review of past and current research regarding language and literacy development in children with mild to severe hearing impairment. A related goal is to identify gaps in the empirical literature and suggest future research directions. Included in the language development review are studies of semantics (vocabulary, novel word learning, and conceptual categories), morphology, and syntax. The literacy section begins by considering dimensions of literacy and the ways in which hearing impairment may influence them. It is followed by a discussion of existing evidence on reading and writing, and highlights key constructs that need to be addressed for a comprehensive understanding of literacy in these children.

By 24 mo of age, most typically developing infants with normal hearing successfully transition to the production of words that can be understood about 50% of the time. This study compares early phonological development in children with and without hearing loss to gain a clearer understanding of the effects of hearing loss in early-identified children. A secondary goal was to identify measures of early phonetic development that are predictors of later speech production outcomes.The vocalizations and early words of 21 infants with normal hearing and 12 early-identified infants with hearing loss were followed longitudinally over a period of 14 mo (from 10 to 24 mo of age). Thirty-minute mother-child interaction samples were video recorded at 6- to 8-wk intervals in a laboratory playroom setting. Vocalizations produced at 16 and 24 mo were categorized according to communicative intent and recognizable words versus other types. Groups were compared on the structural complexity of words produced at 24 mo of age. Parent report measures of vocabulary development were collected from 10 to 30 mo of age, and Goldman-Fristoe Test of Articulation scores at 36 mo were used in regression analyses.Both groups increased the purposeful use of voice between 16 and 24 mo of age. However, at 24 mo of age, the toddlers with hearing loss produced significantly fewer words that could be recognized by their mothers. Their samples were dominated by unintelligible communicative attempts at this age. In contrast, the samples from normal hearing children were dominated by words and phrases. At 24 mo of age, toddlers with normal hearing were more advanced than those with hearing loss on seven measures of the structural complexity of words. The children with normal hearing attempted more complex words and productions were more accurate than those of children with hearing loss. At 10 to 16 mo of age, the groups did not differ significantly on parent-report measures of receptive vocabulary. However, the hearing loss group was much slower to develop expressive vocabulary and demonstrated larger individual differences than the normal hearing group. Six children identified as atypical differed from all other children in vowel accuracy and complexity of word attempts. However, both atypical infants and typical infants with hearing loss were significantly less accurate than normal hearing infants in consonant and word production. Early measures of syllable production predicted unique variance in later speech production and vocabulary outcomes.The transition from babble to words in infants with hearing loss appears to be delayed but parallel to that of infants with normal hearing. These delays appear to exert significant influences on expressive vocabulary development. Parents may appreciate knowing that some children with hearing loss may develop early vocabulary at a slower rate than children with normal hearing. Clinicians should monitor landmarks from babble onset through transitions to words. Indicators of atypical development were delayed and/or limited use of syllables with consonants, vowel errors and limited production of recognizable words.

Infants with hearing loss are known to be slower to develop spoken vocabulary than peers with normal hearing. Previous research demonstrates that they differ from normal-hearing children in several aspects of prelinguistic vocal development. Less is known about the vocalizations of early-identified infants with access to current hearing technologies. This longitudinal study documents changes in prelinguistic vocalizations in early-identified infants with varying degrees of hearing loss, compared with a group of infants with normal hearing. It was hypothesized that infants with hearing loss would demonstrate phonetic delays and that selected aspects of phonetic learning may be differentially affected by restricted auditory access.The vocalizations and early verbalizations of 21 infants with normal hearing and 12 early-identified infants with hearing loss were compared over a period of 14 mo (from 10 to 24 mo of age). Thirty-minute mother-child interaction sessions were video recorded at 6- to 8-wk intervals in a laboratory playroom setting. Syllable complexity changes and consonantal development were quantified from vocalizations and early verbalizations. Early behaviors were related to speech production measures at 36 mo of age. Participants with hearing loss were recruited from local audiology clinics and early intervention programs. Participants with normal hearing were recruited through day care centers and pediatrician offices.Relative to age-matched, normal-hearing peers, children with hearing loss were delayed in the onset of consistent canonical babble. However, certain children with moderately-severe losses babbled on time, and infants with cochlear implants babbled within 2 to 6 mo of implantation. The infants with hearing loss had smaller consonantal inventories and were slower to increase syllable shape complexity than age-matched normal-hearing peers. The overall pattern of results suggested that consonant development in infants with hearing loss was delayed but not qualitatively different from children with normal hearing. Delays appeared to be less pronounced than suggested by previous research. However, fricative/affricate development progressed slowly in infants with hearing loss and divergence from the patterns of normal-hearing children was observed. Six children (2 with normal hearing; 4 with hearing loss) were identified as atypical, based on their rates of development. At 24 mo of age, these children persisted in producing a high proportion (0.59) of vocalizations lacking consonants, which was negatively correlated with Goldman-Fristoe scores at 36 mo (r = -0.60).Results suggest that early-identified children are delayed in consonant and syllable structure development, which may influence early word learning rates. Fricative/affricate development appears to be challenging for some infants with hearing loss. This may be related to the effects of sensorineural hearing loss on high-frequency information, restricted bandwidth provided by amplification, and reduced audibility in contexts of noise and reverberation. Delayed fricative use may have implications for morphological development. Atypically slow rates of change in syllable development may indicate that a child is at risk for delayed speech development.

The main purpose of the current investigation was to determine whether the Vocal Development Landmarks Interview-Experimental Version (VDLI-E) was sensitive to variation in the vocal development of infants and toddlers who are hard of hearing. The VDLI-E is an interactive parent interview that uses audio samples of authentic infant vocalizations to make targeted vocal behaviors clear and understandable to parents without the need for technical terms, verbal descriptions, or adult modeling of infant productions. The VDLI-E was found to be sensitive to age and hearing and was related to performance on concurrent measures of early auditory skills, expressive vocabulary, and overall expressive language abilities. These findings provide preliminary support for the utility of this measure in monitoring the impact of early auditory experiences on vocal development for 6- to 18-month-old children who are hard of hearing.

PurposeThis study examined the effects of consistent hearing aid (HA) use on outcomes in children with mild hearing loss (HL).MethodFive- or 7-year-old children with mild HL were separated into 3 groups on the basis of patterns of daily HA use. Using analyses of variance, we compared outcomes between groups on speech and language tests and a speech perception in noise task. Regression models were used to investigate the influence of cumulative auditory experience (audibility, early intervention, HA use) on outcomes.ResultsFull-time HA users demonstrated significantly higher scores on vocabulary and grammar measures compared with nonusers. There were no significant differences between the 3 groups on articulation or speech perception measures. After controlling for the variance in age at confirmation of HL, level of audibility, and enrollment in early intervention, only amount of daily HA use was a significant predictor of grammar and vocabulary.ConclusionsThe current results provide evidence that children's language development benefits from consistent HA use. Nonusers are at risk in areas such as vocabulary and grammar compared with other children with mild HL who wear HAs regularly. Service providers should work collaboratively to encourage consistent HA use.

Objectives: Children who are hard of hearing (CHH) have restricted access to acoustic and linguistic information. Increased audibility provided by hearing aids (HAs) influences language outcomes, but the advantages of appropriately fit HAs can only be realized if children wear their devices on a consistent basis. The purpose of this article was to characterize long-term HA use in CHH, based on parent-report measures, and identify factors that influence longitudinal trends in HA use. Design: Participants were parents of 290 children with mild to severe hearing loss. At every visit, parents estimated the average amount of time the child used HAs per day during the week and on the weekends. Parent reports of daily HA use were analyzed to determine if different patterns of HA use were observed longitudinally during the study. Independent predictor variables were then related to longitudinal trends in HA use within three age groups (infant, preschool, school age). Results: On average across multiple visits, parents reported that their children wore their HAs for 10.63 hr per day (SD = 3.29). Data logging values were lower than parent-report measures (M = 8.44, SD = 4.06), suggesting that parents overestimated daily HA use. The majority of children in each age group wore HAs at least 8 hr per day from their first research testing interval to their last, based on parent-report measures. Maternal education level predicted longitudinal trends in HA use for infants and school-age CHH. Degree of hearing loss was related to trends in school-age children only. Conclusions: These results indicated that the majority of CHH increased HA use over time, but a sizable minority demonstrated a low level of use or decreased use in the time period studied. Maternal education level influenced longitudinal trends in daily HA use. Degree of hearing loss influenced trends in school-age children only. Audiologists and early intervention service providers might aid in improving HA use by providing regular hands-on training with the HAs and individualized problem-based strategies to address the challenges families experience with attaining a high level of use. Families may also benefit from practical demonstrations of the benefits of consistent HA use, such as hearing loss simulations, examples of listening in noise with and without HAs, or listening to malfunctioning HAs.

OBJECTIVES The primary objective of this study was to examine the quantity and quality of caregiver talk directed to children who are hard of hearing (CHH) compared with children with normal hearing (CNH). For the CHH only, the study explored how caregiver input changed as a function of child age (18 months versus 3 years), which child and family factors contributed to variance in caregiver linguistic input at 18 months and 3 years, and how caregiver talk at 18 months related to child language outcomes at 3 years. DESIGN Participants were 59 CNH and 156 children with bilateral, mild-to-severe hearing loss. When children were approximately 18 months and/or 3 years of age, caregivers and children participated in a 5-min semistructured, conversational interaction. Interactions were transcribed and coded for two features of caregiver input representing quantity (number of total utterances and number of total words) and four features representing quality (number of different words, mean length of utterance in morphemes, proportion of utterances that were high level, and proportion of utterances that were directing). In addition, at the 18-month visit, parents completed a standardized questionnaire regarding their child's communication development. At the 3-year visit, a clinician administered a standardized language measure. RESULTS At the 18-month visit, the CHH were exposed to a greater proportion of directing utterances than the CNH. At the 3-year visit, there were significant differences between the CNH and CHH for number of total words and all four of the quality variables, with the CHH being exposed to fewer words and lower quality input. Caregivers generally provided higher quality input to CHH at the 3-year visit compared with the 18-month visit. At the 18-month visit, quantity variables, but not quality variables, were related to several child and family factors. At the 3-year visit, the variable most strongly related to caregiver input was child language. Longitudinal analyses indicated that quality, but not quantity, of caregiver linguistic input at 18 months was related to child language abilities at 3 years, with directing utterances accounting for significant unique variance in child language outcomes. CONCLUSIONS Although caregivers of CHH increased their use of quality features of linguistic input over time, the differences when compared with CNH suggest that some caregivers may need additional support to provide their children with optimal language learning environments. This is particularly important given the relationships that were identified between quality features of caregivers' linguistic input and children's language abilities. Family supports should include a focus on developing a style that is conversational eliciting as opposed to directive.

Purpose Production accuracy of s-related morphemes was examined in 3-year-olds with mild-to-severe hearing loss, focusing on perceptibility, articulation, and input frequency. Method Morphemes with /s/, /z/, and /ɪz/ as allomorphs (plural, possessive, third-person singular –s, and auxiliary and copula “is”) were analyzed from language samples gathered from 51 children (ages: 2;10 [years;months] to 3;8) who are hard of hearing (HH), all of whom used amplification. Articulation was assessed via the Goldman-Fristoe Test of Articulation–Second Edition, and monomorphemic word final /s/ and /z/ production. Hearing was measured via better ear pure tone average, unaided Speech Intelligibility Index, and aided sensation level of speech at 4 kHz. Results Unlike results reported for children with normal hearing, the group of children who are HH correctly produced the /ɪz/ allomorph more than /s/ and /z/ allomorphs. Relative accuracy levels for morphemes and sentence positions paralleled those of children with normal hearing. The 4-kHz sensation level scores (but not the better ear pure tone average or Speech Intelligibility Index), the Goldman-Fristoe Test of Articulation–Second Edition, and word final s/z use all predicted accuracy. Conclusions Both better hearing and higher articulation scores are associated with improved morpheme production, and better aided audibility in the high frequencies and word final production of s/z are particularly critical for morpheme acquisition in children who are HH.

OBJECTIVE This study examined whether cochlear implant (CI) recipients with substantial preoperative residual hearing obtained more benefit from a CI than from a hearing aid (HA). STUDY DESIGN Retrospective records review. SETTING Tertiary referral center. PATIENTS Thirty-seven CI recipients (11 children/teens, 26 adults) were identified that met the following inclusion criteria: preimplant sentence recognition scores greater than 50% correct in the implanted ear or greater than 60% in the best-aided/binaural condition (Group 1, n = 18); audiometric thresholds less than 70 dB HL at 2 or more frequencies (i.e., better than a severe-profound hearing loss; Group 2, n = 13 ears in 12 recipients), or those that met both the audiometric and sentence-recognition criteria (Group 3, n = 7). MAIN OUTCOME MEASURE Postimplant speech-perception scores. RESULTS Postimplant speech perception was substantially better than the preimplant performance for 12 of 18 recipients in Group 1, 10 of 12 recipients (11/13 ears) in Group 2, and 5 of 7 recipients in Group 3 (total, 73.7%). Five recipients (13.1%) showed no change from preimplant performance levels. Results were inconclusive for 2 recipients (5.3%) because preimplant versus postimplant testing was conducted in different conditions. Three recipients (7.9%) exhibited decreased performance postimplant. CONCLUSION For most recipients whose hearing was better than that defined by traditional candidacy criteria, performance improved with the CI. These results may help clinicians guide candidates in the decision-making process by providing information on the range of outcomes for recipients with similar preimplant performance levels, identify the need for additional preimplant counseling regarding expectations, and recognize the importance of systematizing preimplant and postimplant testing for longitudinal assessment of performance.

OBJECTIVES The objectives of this study were to examine the quantity of adult words, adult-child conversational turns, and electronic media in the auditory environments of toddlers who are hard of hearing (HH) and to examine whether these factors contributed to variability in children's communication outcomes. DESIGN Participants were 28 children with mild to severe hearing loss. Full-day recordings of children's auditory environments were collected within 6 months of their second birthdays by using Language ENvironment Analysis technology. The system analyzes full-day acoustic recordings, yielding estimates of the quantity of adult words, conversational turns, and electronic media exposure in the recordings. Children's communication outcomes were assessed via the receptive and expressive scales of the Mullen Scales of Early Learning at 2 years of age and the Comprehensive Assessment of Spoken Language at 3 years of age. RESULTS On average, the HH toddlers were exposed to approximately 1400 adult words per hour and participated in approximately 60 conversational turns per hour. An average of 8% of each recording was classified as electronic media. However, there was considerable within-group variability on all three measures. Frequency of conversational turns, but not adult words, was positively associated with children's communication outcomes at 2 and 3 years of age. Amount of electronic media exposure was negatively associated with 2-year-old receptive language abilities; however, regression results indicate that the relationship was fully mediated by the quantity of conversational turns. CONCLUSIONS HH toddlers who were engaged in more conversational turns demonstrated stronger linguistic outcomes than HH toddlers who were engaged in fewer conversational turns. The frequency of these interactions was found to be decreased in households with high rates of electronic media exposure. Optimal language-learning environments for HH toddlers include frequent linguistic interactions between parents and children. To support this goal, parents should be encouraged to reduce their children's exposure to electronic media.

Purpose The purpose of the study was to (a) compare the speech sound production abilities of 2-year-old children who are hard of hearing (HH) to children with normal hearing (NH), (b) identify sources of risk for individual children who are HH, and (c) determine whether speech sound production skills at age 2 were predictive of speech sound production skills at age 3. Method Seventy children with bilateral, mild-to-severe hearing loss who use hearing aids and 37 age- and socioeconomic status–matched children with NH participated. Children's speech sound production abilities were assessed at 2 and 3 years of age. Results At age 2, the HH group demonstrated vowel production abilities on par with their NH peers but weaker consonant production abilities. Within the HH group, better outcomes were associated with hearing aid fittings by 6 months of age, hearing loss of less than 45 dB HL, stronger vocabulary scores, and being female. Positive relationships existed between children's speech sound production abilities at 2 and 3 years of age. Conclusion Assessment of early speech sound production abilities in combination with demographic, audiologic, and linguistic variables may be useful in identifying HH children who are at risk for delays in speech sound production.

EI services represent the purpose and goal of the entire EHDI process. Screening and confirmation that a child is D/HH are largely meaningless without appropriate, individualized, targeted and high-quality intervention. For the infant or young child who is D/HH to reach his or her full potential, carefully designed individualized intervention must be implemented promptly, utilizing service providers with optimal knowledge and skill levels and providing services on the basis of research, best practices, and proven models. The delivery of EI services is complex and requires individualization to meet the identified needs of the child and family. Because of the diverse needs of the population of children who are D/HH and their families, well-controlled intervention studies are challenging. At this time, few comparative effectiveness studies have been conducted. Randomized controlled trials are particularly difficult for ethical reasons, making it challenging to establish causal links between interventions and outcomes. EI systems must partner with colleagues in research to document what works for children and families and to strengthen the evidence base supporting practices.

PurposeTo document the epidemiological characteristics of a group of children who are hard of hearing, identify individual predictor variables for timely follow-up after a failed newborn hearing screening, and identify barriers to follow-up encountered by families.MethodThe authors used an accelerated longitudinal design to investigate outcomes for children who are hard of hearing in a large, multicenter study. The present study involved a subgroup of 193 children with hearing loss who did not pass the newborn hearing screening. The authors used available records to capture ages of confirmation of hearing loss, hearing aid fitting, and entry into early intervention. Linear regression models were used to investigate relationships among individual predictor variables and age at each follow-up benchmark.ResultsOf several predictor variables, only higher levels of maternal education were significantly associated with earlier confirmation of hearing loss and fitting of hearing aids; severity of hearing loss was not. No variables were significantly associated with age of entry into early intervention. Each recommended benchmark was met by a majority of children, but only one third met all of the benchmarks within the recommended time frame.ConclusionResults suggest that underserved communities need extra support in navigating steps that follow failed newborn hearing screening.

The present work investigates developmental aspects of the duration of point vowels in children with normal hearing compared to those with hearing aids and cochlear implants at four and five years of age. Younger children produced longer vowels than older children, and children with hearing loss produced longer and more variable vowels than their normal hearing peers. In the current study, children with hearing aids and cochlear implants did not perform differently from each other. Test age and hearing loss did not interact, indicating parallel but delayed development in children with hearing loss compared with their typically-developing peers. Variability was found to be concentrated among the high vowels /u, i/ but not in the low vowels /æ, /. The broad findings of the present work are consistent with previous reports and contribute a detailed description of point vowel duration not in the literature.

Hearing loss is the most common congenital condition screened for at birth in the United States, and 3 per 1000 infants are born with permanent hearing loss. Left undetected, hearing loss in infants can negatively affect speech, language, academic and psychosocial development.1 However, research demonstrates that these negative consequences can be minimized or prevented through early identification and intervention.2–5 Because of this, the National Institutes of Health's Consensus Development Conference on Early Identification of Hearing Loss concluded that all infants should be screened for hearing impairment, preferably prior to hospital discharge.6 Universal Newborn Hearing Screening Programs have been implemented nationwide over the past decade and currently 95% of newborns are screened for hearing loss at birth.1 This initiative was driven in part by the availability of cost-effective and valid objective screening measures, called Otoacoustic Emissions and Auditory Brainstem Response Testing. Although hearing screens are not legally required in all states, voluntary screening augments the newborn hearing screening programs that are legislatively mandated in 43 states.1 Prior to newborn hearing screening, it was common for children with hearing loss to be identified after two years of age or later, resulting in delays in speech, language and social development.1 The expansion of newborn hearing screening in the past decade has been successful in reducing the average age of identification of infants with permanent childhood hearing loss,1,2 allowing families and professionals to optimize infants’ auditory, speech and language learning.2–5 The history of newborn screening and the pathophysiology of hearing loss have recently been reviewed in the Journal of Midwifery and Women’s Health.7 The success of newborn hearing screening programs depends on the ability to link screening with timely and effective diagnosis and intervention. In 2002, the American Academy of Pediatrics (AAP) and the National Center for Hearing Assessment and Management disseminated Guidelines for Pediatric Medical Home Providers, a flowchart that emphasizes the importance of (1) completing newborn hearing screening before 1 month of age, (2) diagnosing hearing loss before 3 months, and (3) enrolling those identified with hearing loss in early intervention before 6 months.8 Accomplishing these goals requires timely follow-up at each stage. Two issues currently threaten the effectiveness of the newborn hearing screening effort: (1) failure to follow-up newborns not passing the initial hearing screen and (2) failure to screen universally. In some regions, follow up rates are as low as 50 percent.4 Midwives can address the rates of screening by ensuring universal testing of all midwifery births, regardless of the place of birth. Midwives can be proactive in urging families to follow through on evaluations and referrals for their newborns who do not pass the initial hearing screen. Midwives are poised during the maternity cycle as educators and advocates to inform families of best practices in newborn hearing screening, with the goal of optimizing hearing health in their children. Studies of the knowledge and practices of healthcare providers related to newborn hearing screening and follow-up are rare. Two recent studies explored the knowledge needs and learning preferences of pediatricians in relation to early hearing detection and intervention.9,10 Results indicated that pediatricians supported the effort, but needed more information on this topic to adequately support families in their care. They requested action-oriented, practical resources that guided them in patient management. To date, no similar studies have been conducted with CMs and CNMs. Because of the role they play in caring for families and newborns immediately after birth, research with this group is critically needed. The current study comprises a national survey of CMs and CNMs on the topic of newborn hearing screening and follow-up. Specific goals of the survey were to understand current midwifery practices related to newborn hearing screening and follow-up, and to assess attitudes and related knowledge needs.

In conclusion, P.L. 99-457 has important implications for professionals who serve hearing-impaired infants and toddlers. The law challenges traditional, child-focused intervention models, and requires professionals to develop programs that are responsive to families' needs. Professionals will need to become familiar with family systems theories, useful family assessment tools, and strategies for collaborative service delivery. Professionals are challenged to determine how enabling relationships can be built with family members. Empowerment of the family system could have far-reaching, positive consequences for the hearing-impaired child.

It has been suggested that manual sign systems designed to represent English are unlearnable because they are not natural languages. In order to examine this premise, the present study examines reading achievement and expressive English skills of 13 profoundly deaf students, aged 7;1 to 14;8, who were educated using only a manually coded English (MCE) sign system. Linguistic structures selected for analysis were designed to reflect unique characteristics of English, as well as those common to English and American Sign Language, and to obtain a broad picture of English skills. Results showed that the deaf students had expressive English skills comparable to a hearing control group for some features of English that reflected syntactic and lexical skills. They showed substantial deficits in inflectional morphological skills that were not predictive of the complexity of their language. The results reveal which aspects of MCE appear to be learnable and which appear problematic for deaf students.

Parental use of simultaneous communication is advocated by many programs serving hearing-impaired students. The purpose of the present study was to describe in detail the input characteristics of five hearing parents, who were attempting to use one such system, Signing Exact English or SEE 2 (Gustason, Pfetzing, & Zawolkow, 1980). The parents were intermediate-level signers, motivated to use SEE 2. Voiced and signed segments from videotaped language samples were transcribed and coded for equivalence and other features of interest. Results were that parents' signed mean lengths of utterance (MLUs) were lower than those of their children although the majority of their sign utterances were syntactically intact. Structures categorized as complex in the Developmental Sentence Scoring procedure (Lee, 1974) and considered abstract in a semantic coding scheme (Lahey, 1988) were seldom used by the parents. Parents provided a narrow range of lexical items in their sign code. Results are discussed in terms of the type of input the parents are providing and the procedures used to identify priorities for parent education.