 Good day. Thank you for joining us in following the development of children in the longitudinal outcomes of children with hearing impairment study or the locky study. In this talk I'll describe the outcomes of children with cochlear implants, look at the factors influencing their outcomes and discuss what the data tell us about how early implantation influenced development. About one to two per thousand newborns have a permanent childhood hearing loss that has a negative impact on children's language and development. The implementation of universal newborn hearing screening makes it possible to detect that hearing loss early so that intervention can start. Early intervention helps to improve children's outcomes, but how early is early? In 2005 we started the locky study. It was during a time in Australia when different states were at different rates of implementing newborn hearing screening. So depending on where a child is born some of the children had access to newborn hearing screening whereas others didn't. Nonetheless all children with hearing loss received the same consistent audiological services from Hearing Australia, a national government funded body that provides hearing services to all families at no cost to them. So by inviting the families of these very young children who came to the hearing centres for services, we, the National Apostolic Laboratories, the Research Arm of Hearing Australia, were able to track the development of these children. We aimed to look at whether early intervention improved language outcomes at a population level, what are the factors influencing the outcomes and specifically whether the access to universal newborn hearing screening improved outcomes. We hypothesized that hearing loss influences language development through its influence on speech perception. And so we used a whole range of measures to measure the outcomes of the children and we collect a whole lot of information about all of these other factors that potentially could influence speech perception and language development. And the study looks at the relationship among all these. Over a period of three years we recruited about 470 children. 29% of them have profound loss and about 20% have a fair loss. 37% have additional disabilities. So once enrolled in the study, we measure their outcomes at 6 and 12 months after the initial feeding of hearing aids or cochlear implant and then again at 3 and 5 and 9 years of age. We've only just commenced our next phase of the study which is assessing these children at 16 years of age. Each of those time intervals we collect the information about all of these factors and we perform assessments of outcomes by using a whole range of standardized tests and other custom design tests. So let's look at the data that we collected when it took room of five years of age. This graph shows the standardized scores of the normative mean of 100 and the standard deviation of 15 and that's shown by that green band. In the horizontal axis you can see a whole range of tests that we have used to assess the children at five years. For some of the tests the performance was within that green band but for some of the other tests they were below that green band. So we used a factor analysis to combine all of these test scores in order to derive what we call a global language score. Then we perform multiple regression analyses using this global language score as a dependent variable and look at the effects of all of those factors that were posited to influence outcomes. In this talk I'll focus on the performance of children with cochlear implants. The regression analysis revealed that the age of first cochlear implants which one was a significant factor so was nonverbal cognitive ability. The severity of hearing loss before implantation however was not a significant predictor. In the second model we also included the other factors and this suggests that the presence of additional disabilities and the use of an oral mode of communication during early education were also significant predictors of outcomes. This graph shows the global language score as a function of the age of first cochlear implant switch on of the children. Imagine if we were to compare the performance of two children the first one received an implant at six months of age and the second one that receives an implant at around 12 months of age and assuming that these children have very similar demographic characteristics. The model predicts that the first child who receives an early implant has a score that is 0.7 of a standard deviation higher than the child who receives an implant at 12 months and imagine if that second child did not receive an implant at 12 months but rather at 80 months or indeed at 24 months then that first child who received an implant at six months is predicted to have a language score of five years that is 1.4 standard deviation above that other child who did not receive an implant until 24 months. Now let's look at the data again when these children were assessed at nine years of age. So at this time we're able to do more testing and so a total of about 41 tests scores contributed to the derivation of that global language score. This graph shows the distribution of the nine-year global language score of the children using cochlear implants. Again we used a multiple regression analysis to find out which are the significant predictors. The analysis revealed that the age of first cochlear implant switch on was a significant predictor and the non-verbal cognitive ability was also a significant predictor. In addition socioeconomic status was also a significant predictor of outcomes at nine years of age. In a second model we needed the early pH score. The pH is a parent report questionnaire that we asked the parents to observe their children in everyday life situations and to range their auditory behavior in real life. This was administered at six and 12 months after initial cochlear implantation and the regression analysis revealed that very early pH score was also a significant predictor of outcomes at nine years of age together with socioeconomic status, non-verbal cognitive ability and the age of first cochlear implant switch on. So if we now look at the global language score as a function of age of first cochlear implant switch on, we see the same trend. The later the cochlear implantation, the lower the language scores at nine years of age. So clearly early intervention is the key to improving outcomes of children. Earlier implantation is associated with better language outcomes at five years and also at nine years. Now these regression models shows us a direct effect of age of implantation on language outcomes. But what's about the other indirect effects, the mediating effects, and what's about the other outcomes? We used a structural equation modelling approach to help us understand this. The analysis revealed that the age of cochlear implantation affects language and speech perception scores by first affecting working memory and maternal education and additional disabilities also affect language and speech perception by first affecting non-verbal cognitive abilities. In a similar vein, they also affect language and speech perceptions through their effects on the working memory. Furthermore, language outcomes were associated with psychosocial outcomes. The better the language outcomes, the better the psychosocial skills and the better the quality of life. So coming back to the question that I posed to you in the beginning of this talk, how early is early? Well if we look at the impact of age of implantation on language and on speech perception and how it first affects the cognitive ability that underpins all that development, then we come to the conclusion to say that very early implantation is very important for that cognitive development to happen. And it has to happen by about nine months of age in order to give a child the best chance to develop those skills for life. I would like to acknowledge the funding support for the Lockheed Study from the National Institutes of Health in the US and the Department of Health in Australia. I would also acknowledge all the support they were getting from all of these agencies that have supported the Lockheed Study and especially the families and children and teachers who participate in the study. Last but not least, the entire Lockheed Team whose intellectual contributions, whose hard work, whose efforts and their continual support for the study has made it possible for me to share these findings with you today. In the later part of the series of these talks, Vicki will also talk to you about the impact of hearing aid prescriptions on performance in children using hearing aids in the Lockheed Study. Thank you for your continued interest in the Lockheed Study. I invite you to visit the website and thank you again for listening.