Effectiveness of Early Intervention in Improving Child Outcomes – current results of a Longitudinal Population Study

creating sound valueTM

Effectiveness of Early Intervention in Improving Child Outcomes – current results

of a Longitudinal Population Study Robert Cowan

Teresa YC Ching and the LOCHI Team

The HEARing Cooperative Research Centre, Australia

Depts of Otolaryngology & Audiology, The University of Melbourne, Australia

National Acoustic Laboratories, Sydney, Australia

www.hearingcrc.org creating sound valueTM www.hearingcrc.org

creating sound valueTM T Ching, NAL, CRC HEAR

We gratefully acknowledge funding support from: NIH/NIDCD Grant: R01DC008080

Commonwealth Government of Australia, OHS, Department of Health, Australia; Australian Hearing,

NSW Department of Health, Australia; Phonak Ltd, Oticon Foundation.

From left to right: Linda Cupples, Louise Martin, Paola Incerti, Megan Gilliver, Kirst Gardner-Berry, Vicky Zhang, Sanna Hou, Vivienne Marnane, Teresa Ching, Miriam Gunnourie, Jessica Sjahalam-King, Lauren Burns, Harvey Dillon, Julia Day, Laura Street, Patricia Van Buynder, Jessica Thompson, Christopher Flynn. www.outcomes.nal.gov.au


Background ~ Why LOCHI? • Congenital hearing loss greatly reduces

children’s language, psychosocial skills, academic attainment and life chances (Thompson et al, 2001; Moeller et al, 2007; Nelson et al, 2008).

• UNHS aims to alleviate huge burden of disability

• 2008 US Preventive Services Task Force – “Moderate certainty that net benefit of screening

all newborn infants for hearing loss is moderate” – Based on a single quasi-randomised trial

• Research on population outcomes scant


Longitudinal Outcomes of Children with Hearing Impairment …

NSW

QLD

VIC

YOB: 2002 – 2007 Recruitment 2005-2007

No prospective study that directly compared outcomes of early- and late-identified children on a population basis.


Aims

• Does UNHS and early intervention improve language outcomes, at a population level?

• What factors influence outcomes?

• Does early performance predict later outcomes?


Participants (n = 451)

T Ching, NAL, HEARing CRC

• Gender: 55% M • Add disabilities: ~24% • Aud Neuropathy: ~ 10% • Parents with no hearing

impairment: ~78% • English used at home:

~79% • Maternal education

(university): ~33% • Enrolled in educational

intervention: ~89% • Oral communication mode:

~75%


YOB: 2002 – 2007 New South Wales (NSW), Queensland (QLD) and Victoria (VIC).

Age at fitting (months)

N

0 5 10 15 20 25 30 35 40 450

50

100

0 5 10 15 20 25 30 35 40 45

0 5 10 15 20 25 30 35 40 450

50

100State: Vic

State: NSW State: Qld

Fit < 6 months: 53%

Participants

NSW 51%

QLD - 21%

VIC 28%

First fit < 6 months: 53 %


Language and Communication Mode

English 81%

Arabic 7%

Auslan 4%

Italian 2%

Cantonese 1%

Vietnamese 1%

Spanish 1%

Greek 1%

Polish 1%

Persian 1%

Oral 75%

Manual 1%

Mixed 24%

Communication Mode

As used in home


We measure outcomes as children grow, …

Evidence-Based Intervention


We collect a range of information

Child • Age at fitting • Age at implantation • Birthweight • Gender • Hearing thresholds • HA – Prescription • Use of device • Additional disabilities • Auditory neuropathy • Aetiology • Cognitive ability

Family •Communication mode • Involvement in intervention • Language used at home • Maternal education • Socio-economic status

Intervention • Age at enrolment • Communication mode • Hours of intervention • Parental involvement


And measure children’s outcomes …

• Expressive Communication

• Auditory comprehension

• Receptive vocab. • Expressive vocab.

Language

• Articulation • Phonological dev • Speech perception • Spatial release

from masking

Speech

• Phonological awareness

• Reading • Spelling • Math reasoning

Literacy & numeracy

• Aural-oral function in real life

• Pragmatics • Mental health • Quality of life

Psycho-social dev.

• Educational attainment

• Employment

Education & employment

• Working memory • Orthographic

learning • Paired associate

learning • Lexical access

Cognition


Genetic testing No changes in 200 of the 363 children tested (55%). Changes with unknown consequences in 32 children (9%).

Henrik Dahl


Hearing Device at 3 years

No CI One CI

(N=74)

Two Cis

(n=60)

No hearing aid 6 13 60

One hearing aid 22 61 -

Two hearing

aids

289 - -


3-year Language and Speech Scores

Social and motor dev

within normal range

Vowel production

within normal range

Receptive and

Expressive Language

below 1 SD

Consonant production below 1SD

Receptive vocabulary

within normal range

Real-life functional

performance below 1 SD


Summary, Yr 3 Data analysis revealed…

T Ching, NAL, Hearing CRC

Lesser hearing loss Early age of implantation Maternal education: university Female

Additional disabilities Low birth weight Low scores shortly after fitting


At 5 Years,…..

No CI One CI Two CIs

No HA 12 14 93

One HA 20 56 -

Two HAs 272 - -

304 70 93

Hearing Devices at Age 5 Years


Age 5 Test scores: 25th, 50th, 75th percentiles…


Psychosocial skills Speech perception


To analyse results,…

• Combine 20 test scores into a global language score using factor analysis,

• Fit regression models separately for: – Children using hearing aids – Children using cochlear implants


Forming a global score

Outcome Factor loading

PLS language expression 0.92

CDI language comprehension 0.90

CDI expressive language 0.87

Peabody picture vocabulary 0.86

PLS auditory comprehension 0.85

DEAP vowel production 0.78

DEAP consonant production 0.73

PEACH 0.63

CDI social score 0.63

TEACH 0.53


Distribution of Global Factor Scores (3yr)

75

Global language outcome score

Normal-hearing children



84

Distribution of Global Language Scores (5 yr) 90

65


Global Language Scores


Predictor Variables Assessed • Age at first fitting • Age at CI activation • 4FA hearing loss • Gender • Birthweight • Presence of additional disabilities • Presence of auditory neuropathy • Hearing aid prescription • Non-verbal cognitive ability • Maternal education • Socio-economic status • Communication mode in early intervention


Children using Hearing Aids


Predictor Significance (p) Impact Age first fit (log) 0.003 4FA hearing loss <0.001 0.01 (-0.33,0.35)

Log Age first fit x 4FA 0.07 -0.12 (-0.25,0.01)

Cognitive ability/WNV <0.001 0.68 (0.57,0.78)

Gender 0.16 2.64 (-1.08, 6.36) Birthweight 0.73 -0.43 (-2.86,2.0)

Other disability 0.04 -4.86 (-9.52,-0.19)

Maternal education (uni re school) <0.001 8.34 (3.53,13.16)

Socio-economic status (dec) 0.39 1.43 (-1.82,4.69)

Communication mode (other re oral) 0.007 -6.57 (-1.68,-0.46)

ANSD 0.59 2.10 (-5.51, 9.72)

HA prescription 0.64 -0.96 (04.96, 3.05)

Early PEACH

R2 = 0.69

Significant Predictors for 243 children with HA

Impact of category change. For continuous variables, variation as per specification.

R2 = 0.74 p – value

0.11

0.002

0.06

<0.001

0.19 0.08

0.13

0.01

0.44

0.009

0.03

R2 = 0.77


Effect of Hearing loss, for different age at fitting

-0.5 SD

-0.3 SD


Effect of Age at Fitting, for different hearing loss

-0.3 SD

-0.3 SD

-0.3 SD


Maternal Education

0.6 SD


Communication Mode in Early Education

-0.5 SD


Children using Cochlear Implants


Predictor Significance (p – value)

Impact

Age first switch on (log) 0.001

4FA hearing loss 0.60 -0.06 (-0.30,0.17)

Cognitive ability/WNV <0.001 0.53 (0.37,0.69)

Gender (Female re male)

0.15 4.84 (-1.73, 11.42)

Birthweight 0.79 0.51 (-3.27,4.3)

Other disability <0.001 -19.1 (-28.39,-9.83)

Maternal education (Dip re school) (university re school)

0.20 4.64 (-4.33,13.61) 8.28 (0.76,17.32)

Socio-economic status (dec) 0.40 2.3 (-3.05, 7.65)

Communication mode in Edn. (other re oral) (changed or nil re oral)

0.04 -12.38 (-24.5,-0.31) 2.56 (-7.42,12.55)

R2 = 0.58

Significant Predictors for 114 children with CI

Impact of category change. For continuous variables, variation as per specification.

R2 = 0.70


0.7 SD

0.37 SD

Age at Switch-On

0.25 SD


Yr 5 Global Language Development …

Higher cognitive ability Lesser hearing loss Earlier age at HA fitting Earlier age of implantation Higher maternal education Oral communication mode

Additional disabilities


Phonological Awareness (n = 144)


T Ching, NAL, HEARing CRC


From early to later outcomes,


B* = 0.45 Adj R2 = 0.19 P < 0.001

Early PEACH and 5-yr Language


If early PEACH were the only predictor,

It accounted for 22% of total variance - HA 17% of total variance - CI


From 3 to 5 years,

HA CI

What enabled some children to close the gap?


Early age at hearing-aid fitting Early age at cochlear implantation

Does UNHS Improve Outcomes?

creating sound valueTM T Ching, NAL, HEARing CRC

At 5 years of age, earlier fitting is associated with better performance (n= 325)


Hearing loss

Language skills

Speech discrimination

ANSD

HA or CI

Gender Early

education

Age at fitting/ implantation

SES Maternal

education/Family Involvement

Language input

Cognition

Literacy

Speech production

and perception

Psycho-emotional outcomes

Why does hearing loss affect language development?


• Early language ability was a significant predictor of language at 5 years

• Early Functional performance in real life (PEACH) was a significant predictor of language at 5 years.

Does Early Performance Predict Outcomes at 5 years?


www.outcomes.nal.gov.au www.nal.gov.au

[email protected]

For information

http://www.nal.gov.au/

mailto:[email protected]


• Streamline services to ensure early fitting and implantation

• Investigate brain functioning and relation to language development and cognition

• Monitor early outcomes to identify children who may be “at-risk” of language impairment – Early functional performance – Objective evaluation of detection (+ discrimination)

• Devise evidence-based strategies for intervention

Our Next 5 Years …


• The child MEG system at Macquarie University is a custom sized whole-head MEG system designed specifically for pre-school aged children.

It consists of 64 first-order sensors, developed in collaboration with the Kanazawa Institute of Technology and the Yokogawa Electric Corp. We are upgrading to 108 sensors in 2012.

‘How is Language Processed?”

Using MEG, we can observe which brain areas are active during language processing and how these different brain areas interact.


Activation of Brain for Tonal Languages


Why Cortical Auditory Evoked Potential?

-CAEP testing is feasible using speech stimuli in HEARLab - can be used for fitting of hearing aids & BAHA, and for fitting CIs

- can be used without sedation by non-experts in standard clinical setting

2

- CAEPs can be reliably generated in response to sound stimuli, for adults and for infants/children


SYDNEY CLUSTER

MELBOURNE CLUSTER

BRISBANE CLUSTER

HEARing CRC Members

50

hear and say centre

This research was financially supported by the HEARing CRC established and supported under the Australian Government’s Cooperative Research Centres Program

www.hearingcrc.org

Effectiveness of Early Intervention in Improving Child Outcomes – current results of a Longitudinal Population Study

Health & Medicine

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