Project ASPIRE:Understanding and Addressing Disparities in Pediatric Hearing Loss

Project ASPIRE:Understanding and Addressing Disparities in Pediatric Hearing Loss

Dana Suskind, MDProfessor, Otolaryngology - Head and Neck Surgery & PediatricsDirector, Pediatric Cochlear Implant ProgramUniversity of Chicago Medicine

Sally Tannenbaum, M.Ed., Cert. LSLS, DTHUniversity of Chicago Medicine

CONFLICT OF INTEREST

• We have no relevant financial relationships with the manufacturers of any of the commercial products and/or providers of commercial services discussed in this CME activity.

• We do not intend to discuss any unapproved/investigative use of a commercial product/device in my presentation.

OUTLINE

• Impact of poverty on child development and educational attainment

• 30 million word gap: foundational impact on early language development

• Closing the gap: the Thirty Million Words Project

• SES disparities in children with hearing loss

• Project ASPIRE: addressing the disparity

CHILDREN BORN INTO POVERTY

• Income inequality has never been greater in this country

• Children are profoundly impacted: 16.1 million children live in poverty

• An additional 16.3 million children are living just above the federal poverty line

(Addy, Engelhardt, & Skinner, 2013)

CHILDREN BORN INTO POVERTY:THE STATS

• Racial and ethnic minorities are disproportionately affected

• Children under 18 living in low-income families in the United States in 2011:

• 11 million (65%) of Latino children

• 6.5 million (65%) of African-American children

• .4 million (63%) of American Indian children

• 12.1 million (31%) of white children

• 1 million (32%) Asian children

(Addy, Engelhardt, & Skinner, 2013)

What does this really mean for a child?

It’s more than just income.

Poverty impacts every aspect of a child’s life.

A LIFE OF POVERTY OFTEN MEANS:

• Limited access to

• health care

• quality education

• healthy food

• safe play and exercise

• Living in more violent and economically depressed neighborhoods

• Precarious or unstable housing

These factors culminate in significant levels of stress that profoundly impact both parents and children.

(Wadsworth & Rienks, 2012)

TOXIC STRESS

• Extreme or prolonged stress can become ‘toxic’ for children and derail healthy development

• ‘Toxic stress’ can negatively impact neural connections in the learning and reasoning parts of the brain

• When experienced in early life, this has long-term consequences on a child’s learning, behavior, and physical and mental health

(Center on the Developing Child, 201; Toxic Stress: the Facts, 2012)

IMPACT ON HEALTH

• Impoverished children at greater risk for:

• Poor physical health

• Chronic health conditions

• Behavioral and emotional problems

(Hughes & Simpson, 1995; Morgan, 2009)

EDUCATIONAL ATTAINMENT

• Only 48% of low-SES children are school-ready by age 5

• 80% or more of African-American and Latino public school students can’t read or do math at grade level in 4th, 8th, and 12th grades

.

(Isaacs, 2012; The state of America’s children, 2011)

EDUCATIONAL ATTAINMENT

• Dropout rate of low-SES children was 5 times greater than higher-SES children in 2009

• Even the highest-scoring low-SES children are much less likely to finish college than their higher-SES counterparts

(Chapman, Laird, Ifill, & Kewal Ramani, 2011; Roy, J, 2005)

This educational attainment gap emerges early in children’s lives.

Clearly, many factors contribute to this gap over a child’s lifetime.

But more and more research indicates that the first few years have the biggest and most lasting impact.

At the root of this achievement gap is a disparity in children’s early language environments:

how and how much parents talk with their children.

THIRTY MILLION WORD GAP

• Hart + Risley:

• High-SES children: 45 million words by age 3

• Low-SES children: 13 million words by age 3

• This 30 million word gap profoundly impacts children’s vocabularies, test scores, and IQs

(Hart & Risley, 1995)

DISPARITIES IN EARLY LANGUAGE ENVIRONMENTS

• Both quantitative and qualitative

• Inequities in parents’ language input include:

• significantly less talk and gesture

• shorter and less complex phrases

• less use of open-ended questions

• greater use of directives

(Hammer, Tomblin, Zhang, & Weiss, 2001; Hoff & Tian, 2005; Huttenlocher, Haight, Selzer, & Lyons, 1991; Reilly et al., 2010; Rowe,

2008; Rowe & Goldin-Meadow, 2009; Hoff, 2012)

DISPARITIES IN EARLY LANGUAGE ENVIRONMENTS

• Decreased parental language input leads to significant disparities in children’s development of:

• vocabulary

• grammar

• narrative skills

• Early literacy skills

• Processing speed

• Disparities in language skills are seen from infancy through high school, and the gap widens with age

(Hoff, 2012; Fernald, Marchman, & Weisleder 2012; Hoff, 2005; Huttenlocher, Waterfall, Vasilyeva, Vevea, Hedges, 2010)

This results in children starting school much less prepared to learn.

• The multifactorial nature of poverty and its impact on children’s development is certainly staggering

• But the profound impact of parents’ language upon development and children’s ultimate trajectories gives us hope

Parents have the power to use their words to grow their children’s brains

• Could we target the SES-achievement gap through an educational program that partners with parents to enrich children’s early language environments?

So we asked:

THE THIRTY MILLION WORDS PROJECT

• 12-week parent-directed behavioral intervention to equip parents with skills to enrich their children’s language environments

THE THIRTY MILLION WORDS PROJECT

What does this have to do with children with hearing loss?

• The disparities noted among typically developing children are compounded in children with hearing loss

• Early language environments have a profound impact on the outcomes of children with hearing loss

TARGETING THE DISPARITY: PROJECT ASPIRE

• Parent-directed program designed to enrich the early language environments of children ages 0-4 with hearing loss

• Listening and spoken language curriculum

• Designed for underserved families but applicable for all

• Provided in addition to Early Intervention

• Now funded: Dept. Education IES

GUIDING PHILOSOPHY

• Parents are children’s first and most important teachers

• Enriching a child’s early language environment occurs through promoting parent-child interactions that have been linked to positive child outcomes

• This does NOT require changing cultural practices and values or idiomatic speech

GOALS

• Equip parents with knowledge of their child’s brain and language development

• Increase parents’ belief that their words have the power to “build their child’s brain” and positively impact their educational outcome

• Increase parents’ language input to enrich their child’s early language environment

CURRICULUM: MORE THAN JUST “TALK”

• Early language strategies include:• child-directed speech• positioning• joint attention• follow the child’s lead• turn taking• wait time and expectant look• routines & repetition• self talk & parallel talk• description and expansion• give choices & open-ended questions• labeling - take the “it” out of your vocabulary • book sharing• eliminate background noise• decreasing TV and technology time

INTERVENTION ELEMENTS

• Coaching method• One-on-one Home Visiting model

• Educational modules• Behavioral strategies

• Video modeling

• Quantitative Linguistic Feedback

• Goal setting

PROJECT ASPIRE

• Parents are partners

• 10 weekly computer-based modules

• Integrate practical strategies for increasing parent talk and turn taking into routines and everyday activities

• Discussion-based, motivational, non-judgment

• Video of parent-child interaction illustrates real-life applications

• Animation takes scientific concepts and makes them user friendly

BEHAVIOR STRATEGIES: VIDEO MODELING

• Interventionist and parent practice new skills on video

• Review and discuss using coaching method

• Gives parents immediate concrete feedback on implementing strategies

BEHAVIOR STRATEGIES: QUANTITATIVE LINGUISTIC FEEDBACK

• LENA’s automated technology grants an unprecedented window into a child’s natural language environment

• Records 10-16 hours• Measures

• adult words• conversational turns• child vocalizations• TV time

(Automatic language assessment in three easy steps, 2011).

BEHAVIOR STRATEGIES: QUANTITATIVE LINGUISTIC FEEDBACK

• Tool for:

• awareness of language input

• feedback

• motivation

• goal setting

(Automatic language assessment in three easy steps, 2011).

PILOT STUDY

• Currently ongoing

• 32 families in Chicagoland area

• Quasi-experimental study

• 3-months post-intervention follow up

PROJECT ASPIRE: NEXT STEPS

• Longitudinal, multi-institutional study

• Identify potential partners to make curriculum accessible nationwide

• ASPIRE Espanol

• Adapt for Telemedicine

• Comprehensive professional learning

• Web-based Community of Practice for ASPIRE Interventionists

IT TAKES A VILLAGE

• Kristin Leffel

• Beth Suskind

• Eileen Graf

• Sally Tannenbaum

• Michelle Havlik

• Lyra Repplinger

• Lia Ferro

• Mary Ellen Nevins

• Marc Hernandez

• Teresa Caraway

• Ereni Katsaggelos

• Jean Desjardin

• Christina Perigoe

I would like to thank Project ASPIRE’s many collaborators:

REFERENCES• Addy, S., Engelhardt, W., & Skinner, C. (2013, January). Basic facts about low-income children. Retrieved from http://www.nccp.org/publications/pub_1074.html#3.

• Automatic language assessment in three easy steps. (2011). Retrieved from http://www.lenafoundation.org/ProSystem/Overview.aspx

• Center on the Developing Child, Harvard University (Producer). (2011). Toxic stress derails healthy development [Online video series]. Retrieved from http://developingchild.harvard.edu/resources/multimedia/videos/three_core_concepts/toxic_stress/.

• Chapman, C., Laird, J., Ifill, N., & Kewal Ramani, A. (2011, October). Trends in high school dropout and completion rates in the United States: 1972-2009. Retrieved from http://nces.ed.gov/pubs2012/2012006.pdf.

• Evans, G. W., Gonnella, C., Marcynyszyn, L. A., Gentile, L., Salpekar, N.. (2005). The role of chaos in poverty and children's socioemotional adjustment. Psychological Science, 16 (7).

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