OBJECTIVES. The objectives of this study were to determine the early language outcomes of children with mild to profound hearing loss, compared with hearing control children, at 12 to 16 months of age and to examine the effects of “very early” enrollment (≤3 months) in early intervention.
METHODS. This was a prospective longitudinal study of the outcomes of a cohort of 30 infants identified in the Rhode Island universal newborn hearing screening program and 96 hearing control subjects. Eligible families with children with all degrees of congenital hearing loss were invited to enroll. Child language skills were assessed by using the MacArthur-Bates Communicative Development Inventory, Words and Gestures, at 12 to 16 months.
RESULTS. Children with moderate/profound hearing loss had significantly lower numbers of phrases understood, words understood, and early, later, and total gestures, compared with children with mild/minimal hearing loss and hearing control subjects. Furthermore, children with hearing loss who were enrolled in early intervention at ≤3 months had significantly higher percentile scores for number of words understood, words produced, and early, later, and total gestures, compared with those enrolled at >3 months. Regression analyses to test the independent effects on language skills of children with hearing loss identified enrollment in early intervention at ≤3 months as an independent predictor of percentile scores for word and early gesture production.
CONCLUSIONS. Very early enrollment (≤3 months) in early intervention has beneficial effects on early language for children with hearing loss. Nevertheless, 12- to 16-month-old children with moderate/profound hearing loss exhibit delayed receptive and expressive language skills in oral and signed English modes, compared with peers with either mild/minimal hearing loss or typical hearing sensitivity.
Congenital hearing loss (HL), which is identified at a rate of 2 to 3 cases per 1000 newborns, is the most frequently occurring birth defect.1–4 Each year in the United States, 8000 to 12000 infants are born with congenital HL. This represents 22 to 33 infants each day. Before the onset of universal newborn hearing screening, the age of identification of permanent HL in the United States was 30 months.5
Early studies indicated that children who were deaf or hard of hearing who were not identified as newborns and did not receive early intervention (EI) for language development steadily fell behind their hearing peers in language, cognitive performance, social skills, literacy, and academic skills with increasing age, resulting in lower potential employment levels as adults.6–9 Evidence regarding the importance of early enrollment in EI to improve the outcomes of children with HL began to accumulate in the 1990s, after Yoshinaga-Itano et al10 reported that children with HL who received intervention services before 6 months of age had language scores comparable to those of hearing children at 3 years of age. National recommendations for early hearing detection and intervention (EHDI) were strengthened to include universal screening by 1 month of age, detection before 3 months, and appropriate intervention no later than 6 months.11
Challenges of outcome studies with children with HL include the following. (1) It is difficult to recruit and to enroll children with a firm diagnosis of HL early in the first year of life. (2) Children with HL represent a heterogeneous population; the type of permanent congenital HL may be sensorineural, permanent conductive, mixed, or neural “auditory neuropathy/dyssynchrony,” responses to hearing sensitivity testing may range from mild to profound and may change over time, the HL may be unilateral or bilateral, and the children may have or develop comorbidities.
Although there is strong evidence that early onset of bilateral moderate, severe, or profound HL compromises communication skills, language, and behavior at school age,12–16 there is increasing evidence that unilateral and mild/minimal HL (≤40 dB) also affects academic and language outcomes at school age.16–22 The long-term consequences of mild/minimal HL have important clinical significance, because in some states infants with minimal or unilateral HL are not eligible for EI part C services from birth to 3 years of age, under the Individuals With Disabilities Education Act. In addition, investigators have yet to address thoroughly “how early” EI services should begin for infants with all degrees of HL.
The cohort consisted of children identified as having congenital HL through the Rhode Island newborn hearing screening program and matched hearing control subjects, who are participating in a longitudinal study of maternal and child outcomes related to hearing screening and HL. In this study, language outcomes at 12 to 16 months of age and the factors that contribute to those outcomes, including the age of entrance into EI, are being examined. The objective of this portion of the study was to determine the early language outcomes of children with moderate/profound HL (>40 dB) or mild/minimal HL (≤40 dB or unilateral HL of any degree), compared with hearing children, at 12 to 16 months of age. The hypotheses were that (1) children with moderate/profound HL would have less-optimal receptive and expressive language development, compared with hearing children, at 12 to 16 months of age; (2) children with mild/minimal HL would have less-optimal receptive and expressive language development, compared with hearing children, at 12 to 16 months of age; and (3) children with HL who started EI services by 3 months of age would have higher scores for early receptive and expressive language development at 12 to 16 months, compared with children with HL who started EI after 3 months of age.
This was a prospective longitudinal study of the language outcomes of a cohort of infants identified in the Rhode Island universal EHDI program who were born between October 15, 2002, and January 31, 2005, and for whom institutional review board approval and informed consent were obtained for participation. Of the 31129 infants screened for HL in Rhode Island during the enrollment period, 64 infants were diagnosed as having congenital HL, 720 infants had false-positive results, and 30345 passed the screening test. Thirty-three (52%) of the 64 infants identified as having HL were enrolled in the initial study and were seen at 6 to 10 months; 30 of 33 were seen at 12 to 16 months (Fig 1). All infants with screening results were eligible, including infants cared for in the NICU and those from non–English-speaking families. All recruitment letters and response forms were mailed in either English or Spanish.
Eligible families with children with all degrees of permanent congenital HL were identified in the Rhode Island tracking database (RITRACK) of hearing assessment data and were recruited either through the Family Guidance program or through the mail (if the family opted not to participate in the Family Guidance program). All children in Rhode Island who were identified as having permanent HL are referred simultaneously to the Family Guidance program and standard part C EI. The Family Guidance program is a statewide specialty EI program in Rhode Island that provides services exclusively to families with infants and toddlers with HL. An integral part of the services addresses the early language acquisition needs unique to infants with HL and sets the stage for the critical milestones of later language development. Mother-child interactions and child behavior are analyzed in home visits and in group sessions so that timely linguistic activities may be adapted and incorporated into the family's daily routine. Family Guidance program service providers support the individual language and modality choices of each family and clearly encourage all gestural, signed, and spoken options that can facilitate each child's language growth.
Inclusion criteria for the HL group included being screened for HL at birth at a Rhode Island hospital during the study period and subsequently being diagnosed as having HL. All infants were screened with a 2-step protocol that included otoacoustic emission testing followed by automated auditory evoked response testing, with outpatient rescreening in cases of hospital testing failure. All patients who experienced screening failure were referred for comprehensive diagnostic testing, which included auditory brainstem response testing, tympanometry, otoacoustic emission testing, and, by 6 months of age, visual reinforcement audiometry. A second diagnostic assessment was required for confirmation of the diagnosis.
Demographic information, neonatal data, and hearing screening/diagnostic test results were collected from the established statewide database (RITRACK). This cohort was enrolled as part of an initial study examining 2 outcomes, that is, (1) the long-term impact on the family of false-positive hearing screening results and (2) the language and behavior outcomes of children identified through the newborn hearing screening program. Therefore, matches for the infants with confirmed HL were in 2 categories, namely, subjects with false-positive hearing screening results and control subjects with hearing screening pass results. Attempts were made to match 1 or 2 subjects with screening pass results and 1 or 2 subjects with false-positive results for each enrolled child with HL. Matches were based on a hierarchical matching procedure using the following characteristics: gender, date of birth (±90 days), hospital of birth, normal nursery versus NICU, maternal education, race/ethnicity, and health insurance. Matching criteria were relaxed when necessary to find sufficient matches. Exceptions were necessary for matching of multiple births.
Enrollment in the study was a lengthy process and depended on 3 steps. First, an audiologist submitted the diagnostic report of a newly identified infant with permanent HL to RITRACK. Second, the research team invited the family to participate. Third, once a family provided informed consent, the matching procedure was initiated to invite families of infants with false-positive and pass results through the mail.
This report covers the initial data gathered at 12 to 16 months of age from a longitudinal prospective cohort study monitoring children with HL and matched control subjects through 48 months of age. Emerging language outcomes and maternal interview data at the beginning stages of support and intervention are presented. Socioeconomic status (SES) data,23 including maternal age, marital status, insurance type, education, occupation, birth order, number of individuals in the household, and race, were collected.
Family Support Scale,24 Family Resource Scale,25 Impact on the Family-Adapted Version G,26 and Parenting Stress Index27 data were obtained through parent interviews during the 12- to 16-month home visit. Because some of the infants with HL were twins or triplets and their siblings with no HL were enrolled, all mothers of multiple births completed separate interviews for each child.
The MacArthur-Bates Communicative Development Inventory (CDI), Words and Gestures,28 was completed by mothers. The validity of the CDI has been determined for a range of populations on multiple levels, including face, content, convergent, concurrent, and predictive validity. It is a normed and validated test that was designed to minimize limitations of parental reports by asking questions about current and emerging language through a recognition format. Studies on the validity of the CDI for children with language impairments and children with HL found that parent reports showed high concurrent validity with other measures of early language behavior.29,30 Receptive and expressive emerging language scores are reported through part I (early words), which includes 33 questions about child comprehension of initial phrases and a 396-word vocabulary checklist, and part II (actions and gestures), which has a 63-gesture checklist. Percentile scores are available for phrases and words understood, words produced, and early, later, and total gestures. The CDI was administered to all English-speaking families. A normed Spanish version was administered and scored for all native Spanish speakers. If signed vocabulary was understood or used by the child, then it was counted accordingly on the English or Spanish version. Only 1 family used American Sign Language (ASL) at home; the ASL version of the CDI was used for that family. Scores are reported separately for that family, because ASL normative values and percentiles are still in development. Scores are also reported separately for 1 control subject whose family members were not native English speakers (specifically, Mandarin).
This was a matched cohort study. For language outcomes, our initial study groups were redefined. To test the impact of degree of HL, the children with HL were divided into 2 groups, that is, children with moderate/profound HL (>40 dB) and those with mild/minimal HL (≤40 dB or unilateral HL of any degree). The children recruited with false-positive screening results and initial pass results were combined into 1 control group of children with no HL, because analysis of the CDI scores for the false-positive and pass control groups identified no differences between these 2 groups. Between-group analysis was performed by using analysis of variance for continuous variables and the χ2 test for categorical variables. Variables that demonstrated significant skew and/or sufficiently differing between-group variances were logarithmically transformed, to normalize the data for parametric analyses.
Multivariate models were constructed for each of the CDI scores (dependent variables). Independent variables identified because of their known potential effects on child language outcomes for the total cohort were NICU care, degree of HL, SES, maternal total resource score, and maternal total support score. Additional regression analyses to test the effects of age of enrollment in EI for the children with HL included degree of HL, NICU versus well-infant nursery care, and entry into EI at ≤3 months versus >3 months. These independent variables were identified because of their known contribution to language. The number of independent variables was limited to 3 because of the sample size.
Thirty children with HL and 96 hearing children were evaluated at 12 to 16 months. Of the 30 children with HL, 12 had mild/minimal HL (unilateral HL or bilateral mild HL, ≤40 dB in the better ear) and 18 had bilateral moderate/profound HL (>40 dB). In the mild/minimal HL group, 10 children had unilateral HL (5 had sensorineural HL ranging from mild to profound, 4 had permanent conductive HL ranging from mild to profound, and 1 had neural auditory neuropathy/dyssynchrony, with unstable responses to hearing sensitivity testing) and 2 had bilateral mild HL (1 had sensorineural HL and 1 had neural auditory neuropathy/dyssynchrony). In the bilateral moderate/profound group, there were 14 children with sensorineural HL (ranging from moderate to profound), 1 with permanent conductive HL (of moderate degree), and 3 with neural auditory neuropathy/dyssynchrony (ranging from moderate to severe). No child had a cochlear implant at the time of the study.
Mothers of infants in the 3 groups were similar in age, marital status, education, insurance status, primary language spoken in the home, and Hollingshead SES status, as shown in Table 1. There were no significant differences identified at the 12- to 16-month visit among the 3 study groups in the maternal responses to the questionnaires on support, resources, impact, and stress. Child characteristics are shown in Table 2. Gender and race were similar across groups, with racial demographic characteristics representative of Rhode Island. Children in the moderate/profound HL group were more likely to be preterm (gestational age of <37 weeks), to have a birth weight of <1500 g, and to receive care in the NICU, compared with children in the mild/minimal HL group and control children. One hundred percent of children in the moderate/profound group and 83% of children in the mild/minimal group were participating in EI, and the majority received both generalized part C EI and specialized services from the Family Guidance program. The frequency of visits from the Family Guidance program for the children with moderate/profound and mild/minimal HL was on average 2.6 visits per month (range: 1–4 visits per month) and 1.2 visits per month (range: 0.4–2 visits per month; P = .0013), respectively. All enrolled families of children with HL participated in EI until age 3. In comparison, 20% of the control subjects were enrolled in EI. Parent reports of ≥1 ear infection by the time of the 12- to 16-month visit did not differ significantly among the 3 study groups (moderate/profound HL: 44%; mild/minimal HL: 75%; control: 57%; P = .253).
Child language outcomes on the CDI at 12 to 16 months are shown in Table 3. The chronologic mean ages for children at the time of the visit were 16.4 ± 2, 15.1 ± 2, and 15.6 ± 2 months for the moderate/profound HL, mild/minimal HL, and control groups, respectively. Raw scores were obtained and percentile scores were calculated on the basis of corrected age for premature infants. Percentile scores were derived systematically for children >16.4 months of age on the basis of percentile trends in the manual, because the manual does not provide percentile scores for >16.4 months of age. Three children with mild/minimal HL and 18 control subjects were >16.4 months of age.
Children in the moderate/profound HL group had significantly lower raw scores than did the 2 comparison groups for phrases understood, words understood, words produced, and early, later, and total gestures. Sixty-five percent of children in the moderate/profound HL group were below the 10th percentile for words understood, compared with 25% of children in the mild/minimal HL group and 33% of children in the control group. The children in the moderate/profound group also had lower percentile scores than the mild/minimal group and the control group for phrases understood, words understood, later gestures, and total gestures. There were no differences among groups in imitation skills. Children in the moderate/profound group were significantly less proficient at labeling than were the other 2 study groups. Overall, children with mild/minimal HL had language skills similar to those of children with no HL. Scores are not presented for 1 child in the moderate/profound group whose family communicates with ASL and 1 control child whose primary language is Mandarin, because the CDI is not standardized for those languages. The mother of the child using ASL reported that the child understood 43 ASL signs and produced 26 ASL signs and 24 gestures. The mother of the child developing spoken Mandarin in the control group reported that her child understood 41 words, produced 2 words, and used 21 gestures from the CDI.
Additional analyses were performed to evaluate the effects of chronologic age of entry into EI on CDI scores for the children with HL. Because 43% of the children with HL were enrolled by 3 months of age, the HL group was divided into those with very early enrollment in EI (≤3 months) and with those enrolled at >3 months. The proportion of children with moderate/profound HL who enrolled in EI at ≤3 months was similar to the proportion of children with mild/minimal HL (moderate/profound HL: 6 of 18 children, 33%; mild/minimal HL: 7 of 12 children, 58%; P = .176). Analyses of language outcomes according to age of enrollment in EI for the children with HL are shown in Table 4. At 12 to 16 months, children with HL who enrolled in EI at ≤3 months had significantly higher raw scores for words produced and early gestures and significantly higher percentile scores for words understood, words produced, early gestures, later gestures, and total gestures, compared with children with HL who enrolled at >3 months. Subgroup analyses, as shown in Table 5, indicated that effects of EI were observed within both the moderate/profound HL group and the mild/minimal HL group. Children in the moderate/profound HL group who enrolled in EI at ≤3 months had significantly higher raw scores and percentile scores for words produced and early gestures. The children with mild/minimal HL who enrolled in EI at ≤3 months showed no effects for words produced but had higher percentile scores for later gestures and total gestures. Univariate analyses were performed to examine the effects of gender and NICU stay on CDI scores for the children with HL. Although no differences were found for gender, NICU stay versus well-infant nursery stay was associated with significantly less-optimal language scores for words understood (51 ± 50 vs 147 ± 92 words; P < .01), words produced (5 ± 7 vs 23 ± 32 words; P < .01), and early (9 ± 5 vs 13 ± 3 gestures; P < .006), later (9 ± 8 vs 18 ± 9 gestures; P < .01), and total (18 ± 12 vs 32 ± 12 gestures; P < .0003) gestures. NICU stay was therefore included in all regression models to predict CDI scores.
Results of regression analyses to predict early language outcomes for the total sample of children are shown in Table 6. NICU care and moderate/profound HL were independent predictors of lower language percentile scores for words understood, phrases understood, later gestures, and total gestures. These 4 models were significant and accounted for 14% to 18% of the variance. Regression models using raw scores or percentile scores provided the same results.
Separate regression models were used for the subgroup of children with HL, to test the effects of EI and degree of HL on language skills. Independent variables were age of entry to EI (≤3 months versus >3 months), degree of HL (moderate/profound versus mild/minimal), and NICU care versus well-infant care. All of the models used to predict CDI scores for infants in the HL group were significant and accounted for 37% to 54% of the variance (Table 7). Enrollment in EI at ≤3 months was associated independently with higher percentile scores for words produced and early gestures. NICU care was associated independently with lower percentile scores for words understood and phrases understood. Moderate/profound HL was associated with lower percentile scores in each model, but this association did not reach statistical significance.
The population of children identified in the Rhode Island EHDI program and enrolled in this study is heterogeneous and includes children who were cared for in the NICU and the well-infant nursery, children with moderate/profound HL and mild/minimal HL, and children who enrolled in EI at ≤3 months and >3 months, which allowed us to evaluate important modifiers of language development. Our prospective study findings partially support our first 2 hypotheses, that children with HL would have less-optimal early receptive and expressive language development, compared with hearing control subjects, at 12 to 16 months. Although children with moderate/profound HL had poorer receptive and expressive language skills, compared with typically hearing control subjects, children with mild/minimal HL performed similarly, compared with typically hearing children, at 12 to 16 months.
All of the children enrolled in the study, except 1, have hearing parents. The 1 child with profound bilateral HL who communicated with his family in ASL had expressive language skills comparable to those of hearing control subjects. This result is similar to the findings reported by Meadow-Orlans et al.31
Current data indicate that the prevalence rate of unilateral HL (moderate or greater in the impaired ear) is 0.41 cases per 1000 in the well-infant nursery and 3.2 cases per 1000 in the NICU.32 Bess and coworkers17,18 reported a mild/minimal HL (15–40 dB) rate of 5.4% in a sample of children in grades 3, 6, and 9; however, population rates of mild/minimal HL (15–40 dB) are not available for the newborn population. Rates of minimal and unilateral HL have been reported to be higher in school-aged children than in neonates. The impact of mild/minimal sensorineural HL on the child can be substantial. Bess et al22 found that 37% of children with unilateral HL failed ≥1 grade. Davis et al21 reported that 44% of children with bilateral mild HL and 40% of children with unilateral HL had difficulty pronouncing certain words. A number of studies of school-aged children have reported delays in speech-language, cognition, vocabulary, verbal ability, and reasoning among children with unilateral HL.33,34 Impaired or delayed use of grammar, vocabulary, phonologic discrimination, and academic skills has been reported for cohorts of school-aged children with bilateral mild/minimal HL.34–42 Competing noise that surrounds a listener hinders accurate speech perception. Therefore, elevated levels of noise in the home and classroom can deleteriously affect speech recognition and psychosocial development in children with each type and degree of HL.42 Environmental factors would be particularly problematic for young children with “unrecognized” unilateral or minimal HL. Although the children with mild/minimal HL in this cohort had early language skills at 12 to 16 months similar to those of children with no HL, future longitudinal evaluations will determine at what age linguistic delays develop for children with mild/minimal HL.
Our data supported our third hypothesis, that children with HL who started EI services by 3 months of age would have more-advanced receptive and expressive language development as early as 12 to 16 months, compared with children with HL who started EI at >3 months of age. Separate analyses demonstrated differential effects of EI for the children with mild/minimal HL (later gestures, total gestures and a trend for early gestures) and those with moderate/profound HL (words produced and early gestures). In examining within-group effects of EI enrollment, it is of interest that words produced (either signed or spoken) and early prelinguistic communicative gestures were affected more by EI in the moderate/profound HL group. These infants participated more frequently in EI and, because of their degree of HL, might have derived greater benefit from EI focused on establishing effective referential communication. Children in the mild/minimal HL group had greater benefit in all types of gestures. Later gestures include more-symbolic play activity, including pretend play and imitating, which may be associated with more-advanced language skills.
There are a limited number of studies evaluating the early effects of EI for children with HL.5–7,10,43,44 Although most studies defined early enrollment in intervention services as 6 months to 14 months of age, Apuzzo and Yoshinaga-Itano7 reported retrospective data on 69 children with HL divided into 4 age-of-identification groups. Their data suggested better language scores for infants diagnosed as having HL in the first 2 months of life. White and White6 reported better language scores for severely and profoundly deaf children with a 14-month age of intervention, compared with 26 months. Moeller43 reported similar results for a cohort of 100 children who were deaf or hard of hearing. That author reported that not only early age of enrollment (<11 months) but also enhanced family involvement in EI predicted better language outcomes at 5 years of age. The study by Yoshinaga-Itano et al10 reported that children identified at <6 months of age who did not have other disabilities and who received intervention services had significantly better language scores at 3 years of age, compared with children identified at >6 months of age. Calderon5 completed a retrospective analysis of data for 28 children with prelingual moderately severe/profound HL who had graduated from EI and were 45 to 88 months of age. That author reported that not only parental involvement with EI but also maternal communication skills were important predictors of language development. Calderon et al9 stressed the importance of recognizing the effects of other family factors, including social support, stress, and mother-child synchrony, on the success of EI. Our study is the first to report improved early language outcomes at 12 to 16 months of age for children with HL with respect to very early (≤3 months) intervention services.
Our findings that maternal stress levels were similar among the study groups at 12 to 16 months are similar to the findings of Pipp-Siegel et al.45 We speculate that, if the family becomes informed and is supported early after the diagnosis of HL is confirmed, then the family members may perceive less stress and impact on their daily lives.46–53
Finally, our regression analyses to predict language outcomes at 12 to 16 months for the total cohort and separately for the children with HL are of interest. For the total cohort, both care in a NICU and moderate/profound HL were associated independently with lower language scores. Infants who require NICU care are known to be at increased risk of developmental delays; therefore, this association was not unexpected. Support, resources, and SES were not associated consistently with the study outcomes in the regression models.
Regression models to predict language scores for the group of children with HL were limited by the sample size to 3 independent variables contributing to early language development. The models accounted for a significant amount of total variance, ranging from 37% to 54%. In contrast to the regression models for the total cohort, the degree of HL did not contribute independently to any of the language outcomes. NICU care provided independent contributions to the models for lower percentile scores for words understood and phrases understood, with trends for association with lower percentile scores for later gestures and total gestures. This suggests that the high-risk status imparted by requiring care in the NICU has a greater impact on language at 12 to 16 months than does the degree of HL. Early enrollment in EI was associated positively with all language outcomes and was associated significantly with higher percentile scores for both words produced and early gestures. The model for the percentile score for words produced accounted for 43% of the variance, with an independent contribution from EI at ≤3 months (31 more percentile points). The model for early gestures accounted for the most variance (51%), with an independent contribution from EI at ≤3 months (37 more percentile points).
The strengths of this prospective study are that the study sample included infants with all degrees of HL, the impact of “very early” enrollment in EI was examined, and this prospective cohort was compared with control subjects with no HL. Weaknesses include the limited number of families with infants with HL born in Rhode Island during the study period that consented to participate in research, an observational study design, and the strong association between being cared for in the NICU and having moderate/profound HL. Although our population of infants with HL was heterogeneous and included infants with 3 variants of permanent HL, differing degrees of HL, unilateral and bilateral HL, and NICU and well-infant nursery care, we consider the heterogeneity a “real world” strength of the study. Despite the heterogeneity of the infants, the mothers had similar socioeconomic characteristics. In addition, the regression models for the total cohort adjusted for degree of HL, NICU care, SES, total support, and total resources and the regression models for the children with HL adjusted for NICU care, degree of HL, and age of entrance into EI. A large, prospective, multicenter study of subgroups of the population is needed to investigate and to compare outcomes of children with different types of HL.
Our findings provide evidence for the beneficial effects of very early enrollment (≤3 months) in EI on early language outcomes of young children with HL. Children with moderate/profound HL who had hearing parents still tended to lag behind children with mild/minimal HL and hearing peers in early receptive and expressive language development at 12 to 16 months. It is not known whether these children will “catch up” with the children with mild/minimal HL as they continue to receive specialized services or whether the children with mild/minimal HL will start to lag behind hearing peers as they have increased exposures to noisy environments and more demands for complex language skills. The single child with bilateral profound HL and parents using ASL had expressive language skills comparable to those of the hearing control subjects. This supports the findings of Meadow-Orlans et al.31 We conclude that all infants diagnosed as having HL benefit from specialized intervention programs that meet their developmental needs and optimize communicative outcomes.10,44,54
This work was funded by a cooperative agreement from the Centers for Disease Control and Prevention (grant UR3/CCU120033-01) and the Association of University Centers on Disabilities (grant AUCD-RTOI 2006-06-07-1).
We express our appreciation to Jyllian Anterni, Cara Dalton, Jennifer Lecomte, Meg Denton, Mary Catherine Hess, Ellen Amore, Peter Simon, Melanie Wilson, Pam Costa, Martha Leonard, Jennifer Sharpe, Susan Clifford, Lucille St Pierre, Joyce Rose, and the families that generously gave their time to participate in this study.
- Accepted December 19, 2007.
- Address correspondence to Betty Vohr, MD, Women and Infants Hospital, 101 Dudley St, Providence, RI 02905. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject
Studies have shown the beneficial effects of early intervention on language skills at 3 and 5 years of age.
What This Study Adds
This is the first prospective study to evaluate the effects of very early intervention (≤3 months) for children with hearing loss on early language outcomes at 12 to 16 months.
- ↵Mehl AL, Thomson V. Newborn hearing screening: the great omission. Pediatrics.1998;101 (1). Available at: www.pediatrics.org/cgi/content/full/101/1/e4
- Finitzo T, Albright K, O'Neal J. The newborn with hearing loss: detection in the nursery. Pediatrics.1998;102 (6):1452– 1460
- ↵Van Naarden K, Decoufle P, Caldwell K. Prevalence and characteristics of children with serious hearing impairment in metropolitan Atlanta, 1991–1993. Pediatrics.1999;103 (3):570– 575
- ↵Calderon R. Parental involvement in deaf children's education programs as a predictor of child's language, early reading, and social-emotional development. J Deaf Stud Deaf Educ.2000;5 (2):140– 155
- ↵White SJ, White REC. The effects of hearing status of the family and age of intervention on receptive and expressive oral language skills in hearing-impaired infants. ASHA Monogr.1987;(26):9– 24
- Fletcher P, German M. Language Acquisition: Studies in First Language Development. Cambridge, England: Cambridge University Press; 1986
- ↵Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL. Language of early- and later-identified children with hearing loss. Pediatrics.1998;102 (5):1161– 1171
- ↵Office of Disease Prevention and Health Promotion. Healthy People 2010, Vol II: Objectives for Improving Health. 2nd ed. Rockville, MD: Office of Disease Prevention and Health Promotion; 2000
- ↵Bess FH, McConnell FE. Audiology, Education and the Hearing Impaired Child. St Louis, MO: Mosby; 1981
- De Villiers PA. Educational implications of deafness: language and literacy. In: Eavey RD, Klein JO, eds. Hearing Loss in Childhood: A Primer: Report of the 102nd Ross Conference on Pediatric Research. Columbus, OH: Ross Laboratories; 1992:127–135
- ↵Bess FH, Tharpe AM. Unilateral hearing impairment in children. Pediatrics.1984;74 (2):206– 216
- ↵Davis A, Reeve K, Hind SB. Children with mild and unilateral hearing loss. In: A Sound Foundation Through Early Amplification 2001: Proceedings of the Second International Conference, Chicago, IL. Stäfa, Switzerland: Phonak; 2001:179–186
- ↵Hollingshead A. Four Factor Index of Social Status. New Haven, CT: Yale University Press; 1975
- ↵Dunst CH, Trivette CM, Jenkins V. Family Support Scale. Cambridge, MA: Brookline Books; 1988
- ↵Abidin RR. Parenting Stress Index. 3rd ed. Lutz, FL: Psychological Assessment Resources; 1995
- ↵Fenson L, Dale PS, Reznick JS, et al. The McArthur Communicative Development Inventories: User's Guide and Technical Manual. San Diego, CA: Thomson Learning; 1993
- ↵Meadow-Orlans KP, Spencer PE, Koester LS. The World of Deaf Infants: A Longitudinal Study. New York, NY: Oxford University Press;2004
- Blair JC, Peterson ME, Viehweg SH. The effects of mild sensorineural hearing loss on academic performance of young school-age children. Volta Rev.1985;87 :87– 93
- Brown J. Examination of grammatical morphemes in the language of hard-of-hearing children. Volta Rev.1984;86 :229– 238
- ↵Moeller MP. Early intervention and language development in children who are deaf and hard of hearing. Pediatrics.2000;106 (3). Available at: www.pediatrics.org/cgi/content/full/106/3/e43
- ↵Pipp-Siegel S, Sedey AL, Yoshinaga-Itano C. Predictors of parental stress in mothers of young children with hearing loss. J Deaf Stud Deaf Educ.2002;7 (1):1– 17
- Calderon R, Greenberg MT, Kusche C. The influence of family coping on the cognitive and social skills of deaf children. In: Martin D, ed. Advances in Cognition, Education and Deafness. Washington, DC: Gallaudet Press; 1991:195–200
- Calderon R, Naidu S. Further support for the benefits of early identification and intervention for children with hearing loss. Volta Rev.2000;100 (5):53– 84
- Calderon R, Greenberg M. Considerations in the adaption of families with school-aged deaf children. In: Marschark M, Clark D, eds. Psychological Perspectives on Deafness. Hillsdale, NJ: Lawrence Erlbaum; 1993
- Calderon R, Greenberg M. Challenges to parents and professionals in promoting social-emotional development in deaf children. In: Spencer PE, Erting CJ, Marschark M, eds. The Deaf Child in the Family and at School: Essays in Honor of Kathryn P. Meadow-Orlans. Hillsdale, NJ: Lawrence Erlbaum; 2000:167–185
- ↵Dromi E, Ingber S. Israeli mothers' expectations from early intervention with their preschool children. J Deaf Stud Deaf Educ.1999;1 (4):50– 68
- Copyright © 2008 by the American Academy of Pediatrics