Presentation given by HEARing CRC CEO Associate Professor Robert Cowan on the Longitudinal Outcomes of Children with Hearing Impairment study at the New Zealand Audiological Society‘s 38th Annual Conference (2-5 July 2014).

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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.orgcreating sound valueTM
www.hearingcrc.org

2. 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

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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

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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.

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Aims
• Does UNHS and early intervention improve
language outcomes, at a population level?
• What factors influence outcomes?
• Does early performance predict later
outcomes?

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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%

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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 45
0
50
100
0 5 10 15 20 25 30 35 40 45
0 5 10 15 20 25 30 35 40 45
0
50
100
State: Vic
State: NSW State: Qld
Fit < 6 months: 53%
Participants
NSW
51%
QLD -
21%
VIC
28%
First fit < 6 months: 53 %

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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

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We measure outcomes as children grow, …
Evidence-Based Intervention

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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

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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

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

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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 - -

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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

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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

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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

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

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Psychosocial skills Speech perception

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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

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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

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Distribution of Global Factor Scores
(3yr)
75
Global language outcome score
Normal-hearing
children

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Normal-hearing
children
84
Distribution of Global Language Scores
(5 yr) 90
65

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Global Language Scores

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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

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Children using Hearing Aids

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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

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Effect of Hearing loss, for different age at fitting
-0.5 SD
-0.3 SD

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Effect of Age at Fitting, for different hearing loss
-0.3 SD
-0.3 SD
-0.3 SD

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Maternal Education
0.6 SD

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Communication Mode in Early Education
-0.5 SD

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Children using Cochlear Implants

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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

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0.7 SD
0.37
SD
Age at Switch-On
0.25
SD

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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

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Phonological Awareness (n = 144)
Normal-hearing children
T Ching, NAL, HEARing CRC

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From early to later outcomes,

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B* = 0.45
Adj R2 = 0.19
P < 0.001
Early PEACH and 5-yr Language

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If early PEACH were the only predictor,
It accounted for
22% of total variance - HA
17% of total variance - CI

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From 3 to 5 years,
HA CI
What enabled some children to close the gap?

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Early age at hearing-aid fitting
Early age at cochlear implantation
Does UNHS Improve Outcomes?

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

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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?

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• 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?

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www.outcomes.nal.gov.au
www.nal.gov.au
Teresa.Ching@nal.gov.au
For information

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• 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 …

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• 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.

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Activation of Brain for Tonal Languages

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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

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