Minimal Hearing Loss: Impact & Treatment

1. Minimal Hearing Loss: Impact & Treatment Arlene Stredler Brown Colorado School for the Deaf and the Blind (CSDB) University of Colorado - Boulder Marion Downs Hearing Center @ University of Colorado Hospital

2. Collecting the Evidence; Asking the Questions • A portion of school-age children with unilateral hearing loss experience academic delays….. Do children with UHL, in the birth – 3 population, experience delays? If so, is the percentage the same? • Do children, birth – 3, with minimal hearing loss require intervention?

3. Part C Eligibility for Children with Minimal Hearing Loss.. (NCHAM Survey, 2002) • 46 states (including DC) reporting: • All 46 states have established risk conditions that make a child eligible for Part C-funded services • 40 states list specific conditions for eligibility • 30 states note hearing loss as a specific condition • 15 states operationally define hearing loss in their State Plan or other official documents

4. State of the States • 11 states define mild hearing as eligible for Part C services • 7 states define UHL as eligible for Part C services (some limit degree of hearing loss) • Some states require an eligible condition to be associated with a “high probability of significant developmental delay” (>90%) • Some states determine eligibility if/when “appropriate treatment still leaves significant impairment”

5. Eligibility for EHDI Programs • Each state operationally defines their own screening procedures, diagnostic criteria, and early intervention • Intervention is, to varying degrees, determined in collaboration with different initiatives & funding sources • Part C • Schools for the Deaf • Private treatment centers

6. Collecting the Evidence Mild Hearing Loss

7. Mild Hearing Loss: Colorado Outcome Data • As a group, children with mild, bilateral hearing loss have better language skills than children with more severe degrees of hearing loss • As a group, children with mild, bilateral hearing loss do not have language quotients comparable to their hearing peers

8. Treatment Data • Colorado’s model supports direct services to all children with bilateral, mild hearing loss • Intensity of services is identified on the IFSP

9. Mild Loss Moderate Loss Moderate / Severe Severe Loss Profound Loss Mom < HS Education Mom > HS Education No Medicaid Medicaid Hearing Loss Only Multiple Disabilities By 6 Months After 6 Months The early identification effect on language (N=85) MCDI Total Language Quotient (Mean) Yoshinaga-Itano, et al (1998)

10. Collecting the Evidence Unilateral Hearing Loss

11. History of the Colorado Project… • Identification of need subsequent to the start of UNHS • BCHD repeatedly asked for guidance for families of very young children with UHL • Started in 1997 by the Colorado Home Intervention Program (CHIP) at the Colorado School for the Deaf and the Blind (CSDB) in collaboration with the University of Colorado-Boulder

12. History • Purpose: To identify if the negative impact of UHL on some school-age children is apparent during the birth – 5 years • Purpose: To confirm a need to change current practices regarding young children with UHL • “Don’t worry, your child has one good ear”. • “Be sure to arrange for preferential seating when your child starts school”.

13. Guiding Principles • Establish an assessment protocol to monitor development of individual children and the total group • A professional with expertise related to hearing loss is the family’s primary contact person, answers questions, provides consultation • The audiologist coordinates with the other professionals involved in the child’s/family’s care; physician, clinical audiologist, Part C service coordinator, direct service providers

14. Participants in the Project • Six counties in Denver-metro area • 30 children in the original database • Identified by diagnosing audiologist and/or EHDI database at CDPHE • Designated service coordinator (a clinical audiologist) contacts families • Initial contact by phone • Offers home visit • Provides written materials: UHL brochure, CHIP brochure, “Tips for UHL”, current articles • Explains pilot project including FAMILY Assessment

15. The FAMILY Assessment • Multi-disciplinary assessment consisting of videotaped interaction and parent-completed protocols • Receptive & expressive language: vocabulary, syntax, speech intelligibility, articulation • Cognitive/play skills • Gross/fine motor skills • Social-emotional skills • Functional auditory skill development • Functional vision checklist • Family Needs Survey

16. Unilateral to Bilateral Loss • 30 children initially identified with unilateral loss • 2 (7%) progressed to bilateral within first year of life • 2 (7%) later diagnosed with bilateral losses that apparently were present from birth • One mild (30dB) in poorer ear • One moderate low frequency loss with normal high frequency hearing

17. State of Residence

18. Gender

19. Ethnicity

20. Additional Disabilities

21. Socio-Economic Status 1n = 24 2n = 22

22. Mode of Communication

23. Newborn Hearing Screening

24. Age of Identification N = 24

25. Age of Onset N = 25

26. Etiology

27. Malformation of Ear Structures

28. Ear with Hearing Loss

29. Degree of Loss N = 25

30. Language Ability • Assessments: • Minnesota Child Development Inventory • MacArthur Communicative Development Inventories • Spontaneous language sample

31. Minnesota Inventory • Participant Description: • 18 children • No additional disabilities • Selected oldest age available • Chronological age: • Range = 7 to 59 months • Mean = 25 months

32. Minnesota Inventory • Test Description • Parent report questionnaire • Expressive and receptive language subscales • Language Quotient (LQ) derived • Language age/Chronological age x 100 • LQ of 100 means language age = chronological age

33. Minnesota Inventory 5% of hearing children borderline or below average

34. MacArthur Inventory: Expressive • Participant Description: • 12 children • No additional disabilities • Chronological age: • Range = 14 to 28 months • Mean = 21 months

35. MacArthur Inventory: Receptive • Participant Description: • 11 children • No additional disabilities • Selected all children who were the appropriate age for the test • Chronological age: • Range = 12 to 16 months • Mean = 14.5 months

36. MacArthur Inventories • Test Description • Assesses vocabulary abilities • Parent report questionnaire • Parent indicates words child can understand and produce • Percentile scores determined relative to test norms

37. MacArthur Inventories 10% of hearing children would be expected to fall below the 10th percentile

38. Spontaneous Language Sample • Participant Description: • 15 children • No additional disabilities • Selected oldest age available for each child • Chronological age: • Range = 15 to 62 months • Mean = 29 months

39. Spontaneous Language Sample • Mean Length of Utterance (MLU) • 10 (67%) children within age expectations • 5 (33%) children below age expectations

40. Summary of Language Results • 15 children examined across measures and time • Considered assessments after 12 months of age • No additional disabilities • Number of children with language delays • Delayed = 4 (27%) • Borderline = 1 (7%)

41. Profile of 4 Children with Delays • Caucasian • Identified by 2 months of age • Congenital • Etiology unknown • Parents use oral communication only • Parental education 16 years or more • Annual income > $80,000

42. Profile of Children with Delays • No outer or middle ear malformation • Affected ear: 50% right, 50% left • Degree of loss • All “severe or profound” (i.e., no response on ABR) or profound

43. Current Case Studies from Colorado • 5 children with delays on developmental assessments • Chronological ages: 1-5 to 1-11 • Developmental delays in the following areas • Vocabulary development (n=5) • Receptive language (n=1) • MLU (n=1) • Speech development (n=1)

44. Let’s remember…… Minimal is not inconsequential Bess, 2004