 Hi everyone, it's Sarah Burns. We're just really excited here to have Dr. Mary Pat Moller here to speak about the audiological and educational needs of children. I had the opportunity to meet, well actually I took the opportunity to meet Mary Pat Moller last fall. We were heading off to an event at a conference in Atlanta and she, fortunate for me, took the window seat in the bus and I took the aisle seat and I captured her in there and talked her ear off about what we're doing up here in Alberta, creating professional learning communities. And I think near the end of the bus ride, I asked if she'd be willing to present and then emailed her after the conference. Dr. Moller is the director of the Center for Childhood Deafness at Boyscom National Research Hospital in Omaha, Nebraska for a Deaf and Hard of Hearing. And she's published and lectured internationally on topics related to early development in children with hearing loss and is one of the co-principal investigators on the bulky state study on the outcomes of children with mild to severe hearing loss. And I don't want to take from her because when I looked at her slides, there was a great deal of information from far away. Thank you. I suspect it's way more beautiful there than it is here in Omaha, but I'm delighted to be able to join you on webinar. And I thank Sarah for inviting me to conduct this seminar today. It's an honor and a pleasure to be with you. We are in the process of conducting a large scale longitudinal study of children who are hard of hearing. And today I'm going to share some of the results from that study that are pertinent to the issues you might be experiencing with these children in your program. I'll especially pay attention to children in the mild and mild-moderate level categories. This work is a collaboration at Boys Town with the University of Iowa and the University of North Carolina at Chapel Hill. Now it's difficult to talk about hard of hearing children without mentioning the early seminal work of Julia Davis. Some of you might recall that Julia Davis talked about hard of hearing children as our forgotten children. She pointed to the lack of studies we had on this group of children and the problem of trying to extend studies on deaf children to this group of children. They may not be applicable. Our grant agency, the National Institutes of Health, also realized they had funded many studies on children with cochlear implants, many studies on sign language, but they had funded very little work on children who are hard of hearing. I also want to note why, why were some other reasons that Julia Davis called this group our forgotten children a number of years ago? First of all, she noted that educators and parents might often underestimate the needs of these children. Sometimes they use spoken language a little bit too well. They talk too well. And so there's subtle challenges with language are not recognized. I remember a regular educator saying to me, oh, he hears me just fine. He just doesn't pay attention. And that comment revealed this tendency to not appreciate perhaps some of the subtle struggles in language and learning. Similarly, she pointed to the limited training that regular educators or school administrators might have regarding this group of children. And she noted that we really didn't have a very good understanding of their educational achievements, whether or not they were socially accepted in the classroom and what kind of support services were they getting and did those services make any difference for the children. Finally, she remarked that if they had amplification, it was typically poorly monitored. So I would like to look at this list and then suggest that it begs the question, are any of these issues still true today? Perhaps in your program, which sounds like it has some real strengths, you have addressed some of these, but I can tell you we're still struggling with many of these issues in the United States. And to complicate matters, there's a lot of ambiguity in the literature about how much risk is presented by children who have mild or mild moderate hearing loss. Do we expect them to fall behind? If we look at a number of studies, the studies I've listed in the blue, all conclude that all children who are hard of hearing, including those children with mild hearing levels, have risk for language delay, particularly in the areas of speech and grammar. If we look at the studies listed in purple, they suggest that many children who are hard of hearing function just like their hearing peers, and if they don't, perhaps they have a language disorder. So there's controversy in the field. And I'd like to point out, though, that the sample sizes in these studies are really small. Look at that, they range from about 13 to 40, and also they invariably include school-aged children. So we don't know much about these preschoolers who are now early identified and receive amplification. Something else really interesting is that most of the older studies didn't even tell us if the children had hearing aids, but alone if their hearing aid fittings were making a difference in language learning. So that's where we come in. We started this OCHL study, or Outcomes of Children with Hearing Law Study, in response to these research gaps. At the foundation of our work is the belief for the recognition that children's exposure to language input is essential to their language development. It's well documented that children who are exposed to more words, for example, have larger, richer vocabularies, and better processing efficiency than children who are exposed to fewer words. There's also extensive research showing that when young children are learning language, they're drawing heavily on statistical learning processes. In other words, children are pattern detectors. They find regular and predictable patterns in the input, and that helps them find word boundaries in order to learn words and early grammar. Well, that ability, if you're learning spoken language, requires access to acoustic phonetic properties in the input, and those are sometimes subtle. We realize that for some children who are hard of hearing, the consistency and quality of their access to the input could be affected. Furthermore, we recognize that accessing the language input around you as well as quality interaction with adults, both of those matter for children's language development. In some cases of children you're thinking of, it may be that both of these factors are altered by the presence of hearing loss early in development. So why is it that we think we believe that children who are hard of hearing get inconsistent access to spoken language input, to the language spoken around them? And why is it that we think that they might have inconsistent access? Well, you probably see this every day, but there are several I'll point out. First of all, hearing aids, as we know, are imperfect. They have some limitations. For example, it's hard for children to perceive sounds like S, if the bandwidth of their hearing aids is limited, and S is important for learning English, at least through spoken form. Furthermore, we know that children don't live in quiet audiology suites, right? They come in and out of noisy and reverberant environments, and this might further impact the fidelity of the speech signal that they are able to access. You'll hear me say access a lot. It's a lot about children's access to the linguistic input. Also, distance from the talker. We could imagine that this little one has really good access to the signal because she's in face-to-face communication compared to this little girl with white hair who's on the swings and is several feet away from her mother. So these factors influence the audibility. That is how accessible and audible is the input the children are receiving with their hearing aids. Furthermore, there are delays in hearing aid fitting. Even in an era of newborn hearing screening, a number of recent research articles say that the average age of fitting is six to 11 months. So there is a period without amplification, an early and important period without amplification. And we know that once hearing aids are fit, there's variation in children's daily use of hearing aids, especially in younger children. I always comment that I was kind of naive about this. I was excited when newborn hearing screening was implemented. And I thought, oh boy, we're going to fit hearing aids when these infants are so young, they're going to get used to them and just leave them alone. And I hope you're laughing at me because that was not the case. And I was doing longitudinal work in my lab and watched one little boy pull his hearing aids out 14 consecutive times. And that patient mother reinserting them over and over again. Finally, the child had a meltdown and the mother decided to give the hearing aid a rest for a short period. And I actually believe that was a good parenting decision in that case. So we do know there's variation in children's use that might affect their access to quality language input. So both of those factors are also going to affect audibility in it and how it influences language over time. Finally, it's likely that the children we work with receive variations in the quality of exposure to language they receive in the home. And so we believe all of these factors may be impacting both the quality and quantity of the child's access to spoken language and that that is going to have consequences for their language development over time. So these thoughts about barriers to access led us to suggest a model of factors that might be influencing children's access and thus their language outcomes over time. Now, I'm sure you know that a number of investigators have tried to tie degree of hearing loss to children's language outcomes. And it happens that if you look at the heart of hearing children, the results are really mixed and that association or link is often not found. However, I'd like to suggest to you it's really unlikely that pure tone average is going to operate alone in influencing children's outcomes. And also pure tone average, as you know, it doesn't represent how children are learning language every day when they're using amplification. So it would be helpful to know how they're performing with amplification. So this led us to suggest that there are at least three primary factors and there's likely many more. But we went about testing this model of three factors that we believe would influence this relationship between pure tone average and children's outcomes. And those three factors include the child's audibility or how well they're able to hear spoken language with their amplification on. Secondly, their consistency and duration of hearing aid use. And thirdly, the quality of the linguistic input that the child is exposed to in the home. So we went about trying to look at these factors and what they might explain about what we need to do with children and why we see variation in outcomes. So I'm going to begin with just giving you a little background on method and then we'll get into the nitty-gritty some of the results and what they mean for you. So first method and study design. This has an interesting approach. It's called an accelerated longitudinal design. If we had started this study by only enrolling babies and following them forward, we would have never achieved the sample size we needed to answer our research questions. So instead in the first two years of the grant, we found every eligible child we could between six months and six years of age. And wherever they entered on that timeline, they moved forward for three to four years. So let me show you here by illustrating it. So if a child entered at 24 months, we gathered retrospective records shown here and then followed that child prospectively for at least three years. Suppose the child entered at three. Again, we would collect background records and then test the child for at least three years going forward. And similarly, four years of age, you see the same thing unfolding. What I didn't realize is there are a couple of nice features of this design that became more clear as we work that we could drop into any single year and look at our cross-sectional results. But now I'm able to tell you this full longitudinal picture and also as these children aged up, our sample sizes got larger throughout. So it was a useful design for looking at the longitudinal as well as cross-sectional data. What were the inclusion criteria? First of all, the families needed to be speaking English in the home. These children had no significant secondary cognitive motor or visual delays actually. They had permanent bilateral hearing loss. You see the range there. And these were not children who were eligible for cochlear implants. So let me show you our subject numbers. We were successful in recruiting 317 children who were hard of hearing. And they were matched to hearing children that were 117 of those. I want to point out that the mean better ear puritone average is in the moderate range. And here you see our distribution. So today I can talk to you about those mild and moderate children because they made up the bulk of our population. Only seven children in this study were not fit with amplification. 76% of them were identified through newborn hearing screening. Interestingly, those kids that came through newborn hearing screening were identified or confirmed by seven months on average, whereas the late group was around 29 months. Just interesting to see that difference. Also, I'd like to point out that our groups, the children who hear and our children who are hard of hearing were very well matched on income and maternal education. But both groups were somewhat higher than a typical U.S. sample. We worked hard not to just have Lake Wobagon smart children or university city children, but it is a common problem in longitudinal studies that families who will commit to coming in year after year tend to be somewhat more advantaged. But it's important for you to consider that as you look at the results. Children from lower socioeconomic conditions might not be faring as well as the children I'll show you. And if we look at a map of the U.S., you'll see our kids were distributed widely. They came from 17 different states. And we had a low attrition rate of fortune. That was fortunate. It was less than 10%. So we measured lots of different variables, but today I'm going to focus on hearing and language skills as I speak with you. The children did these comprehensive test batteries. And in audiology, the children were seen every year by a team of pediatric audiologists who did full pediatric audiological assessments and verification and validation of hearing aids each year. So some results. I'm going to start with some big picture findings. I always like to start with the big picture and then drill down. And then we'll talk about some factors we identified that do explain individual differences in our children. And what might we do about those? How can we optimize development for the majority of our children? And then I'm going to wrap up with pointing to some of our findings about areas that appear to be particularly challenging for children who are hard of hearing because those might be areas that we want to be more vigilant about or give more intervention. So here we go with the first figure. Let me break this down for you. What you're seeing here is a language score for each child at each age who contributed at two through six years of age. And you see the ends here. This is hearing children hard of hearing for each of those age bins. And this gray area is the average range on this composite language measure. The composite was derived from a variety of different age appropriate language measures to come up with this one measure. Now what I want to point out is that at every age, the children who are hard of hearing are significantly lower than the matched peers. You see that here. And by five to six years of age, that difference is nearly one standard deviation. Now you might argue with me, but look, they're falling within the average range and some kids are doing quite well. So we can celebrate the kids doing quite well. But our view is reliance on just standardized measures to compare these children may result in us underestimating their needs. Why do I say that? Because these matched peers are the children with whom they're competing in school. And they're falling significantly below that performance. So this has led us to conclude that children who are hard of hearing are at risk for depressed language development even when they're identified early. It also calls into question reliance only on standardized measures to ascertain whether children need support. So my overarching theme is, we need to be vigilant these children and ensure they're getting the support they need. Now here's another slide. We found that risk that I mentioned increases with degree of hearing loss. In the next several slides, you're going to now see the longitudinal data. These are growth curves. How language changes over time between two and six years of age. And these are plotted by our hearing children, mild, moderate, and severe. So what you notice right away is there is a systematic relationship between degree of hearing loss and children's language levels. So children with greater hearing loss in this group are at increased risk. So those with moderate, severe hearing loss are at the most risk. However, I'd also like to point out that every one of these groups was significantly different than the control group. And look at the mild children see the gap from their typical peers. We believe we can close that gap by being vigilant and attentive to these children. So also we notice these slopes are parallel. And that means these groups maintain their relative status over time compared to the hearing group. That is, there wasn't some kind of catching up or differentiation. And again, all groups are different than their typical peers, including the mild group. Now, I'd like to argue that you've probably seen in practice, but degree of hearing loss just doesn't explain it all. That's what I've been arguing. And you and I know children with the same audiogram and very different outcomes. So I'm going to have you experience that from our own studies for just a moment that certainly degree of hearing loss won't explain it all. These are two children who are three years of age, both picked up in newborn hearing screening, both amplified early, both with moderate hearing loss. Their outcomes are vastly different. Let's hear the little boy who shows us an ideal outcome. It could be celery. I think it's flowers. Real big flowers. Yeah, honey, it's flowers. Do you think the little girl is happier? Yes. What do you think she said? Because. Because what? She wants more flowers. She wants more flowers. Yeah. What do you think she's thinking about? Yeah. She's thinking about flowers. Yeah. Yep. Now this little one was actually in another study that I had done. And she was at the top of the curve around 16 months, but family circumstances prompted a move to another state. She did not get linked into early intervention and stopped wearing her hearing aids between 16 months and three years of age. She popped back up in my lab at three years of age. And I got this video. All you're going to hear is a lot of complex jargon and a few true words. So we all know that's not typical language development for 36 months of age. And she did get better once she started wearing amplification again. But she gave me an important lesson about we need to look at that variable as potentially influential, particularly with young children. So that brings me back to this issue of audibility, hearing aid use, linguistic input, all appear to be important. So let's start with audibility, which I understand you are doing a good job in your program of using prescriptive methods and validation. It's a common practice. So I'm going to show you how to do that. I'm going to show you how to do that. I'm going to show you how to do that. I'm going to show you how to do that. I'm going to show you how to use prescriptive methods and validation. It's a common practice. So I applaud you because we found in the U.S. there was variation. Some audiologists aren't using those methods. And we found a large number of children who were under fit. So I want to argue just that you're doing a good job. And it matters because audibility we found contributed significantly to language growth. This means language is getting stronger between two and six. This means not much change or kind of falling off. These are the children who had the best aided audibility. These are the children who had the poorest aided audibility. And so what we found is that the amount of benefit and audibility you get from your devices contributes to a stronger growth of language over time. Whereas children with poorest audibility showed no change in language growth over time. And so you see that at two years of age the kids are clustered. But by six years of age that difference was ten standard score points. Nearly two thirds of a standard deviation. So audibility matters for language growth rate. Isn't that exciting? That finding suggests that the work you're doing really pays off. And this benefit was true even for children with mild hearing loss. So audibility matters for that group as well. Children who get the most benefit from their hearing aids show steeper growth in spoken language skills. What about hearing aid use? Consistency and duration. Well, first of all, here were some ways we measured it. We used objective measures like data logging from the children's digital hearing aids. But we also surveyed the parents using a subjective scale where we asked them to report how many hours a day they thought the child was using the hearing aids. And then we had them rate the consistency across daily situations and talk about any challenges to hearing aid use. In this next section I'm going to review some data from those. This work was led by my colleague Beth Walker. And these are data logging values at three different ages. Infant, preschool, school age. Notice that we want full waking hours, right? But the average for the infants in this group was only 4.36 hours. It falls really short of our goal. And this is a particularly sensitive period of language learning. It's fortunate that that improves with time. And here you see there's a big range, however, and how much the children are utilizing their devices. But at least we see the average improving over time. We found that maternal education was a significant predictor. Mothers with more education had children who wore their hearing aids more consistently and vice versa. Also, degree of hearing loss was influential. Children with mild hearing loss were less consistent users. And I'm going to show you why that's problematic in just a moment. So think about these factors when we think about who's at risk for language delays. Does being a consistently poor user of hearing aids affect cumulative language experience and language growth? We suspect that it does. And here's the answer to that question. Does it matter? Yes, it matters. Here we've split the children, again, a longitudinal growth curve from two to six years. But we've got kids wearing their devices less than 10 hours a day, greater than 10 hours a day. And you see that acceleration or language growth as a result of consistent hearing aid use. That's really important. That's what we want, not that. And so we see this large gap by six years of age, again, as a result of inconsistent hearing aid use. So our conclusion is that children who wear their hearing aids more than 10 hours a day show a steeper growth in their language skills. And you see that impact even greater as it accumulates over time. They had better skills than kids who were wearing their hearing aids less often. Now I want to turn to some results just on this mild group and their hearing aid use. This was a paper we published in JSLHR in 2015. And we looked at the hearing aid use of just mild children with mild loss at five and seven years of age. And we sorted them, as you can see, into full-time users, part-time users, and non-users or very low users. Notice the non-users have less degree of hearing loss, although that was not significant. But look at how the average use dropped in these groups. And they were not different on other important variables. So what did we find out about these kiddos? In this slide on the left, we have Peabody Picture Vocabulary Test Standard scores for full-time users compared to non-users. And what we see here is a couple of interesting things that is a significant difference, although you notice that the non-users are still in the average range. However, this is interesting. Our full-time users were in the high average range and they were the group that matched our hearing children. They matched the hearing peers on that. That's where we want them. And then I'd like to point over here to Grammar, the self-scaled score that is the test of grammar production. Again, contrasting full-time users to non-users. And now that difference is 2.5 standard deviations. I'll talk a little later that we think Grammar is particularly at risk in these children. And so we see that impact for the mild group. Their average is at the borderline to below average range, not where we need them to be performing. So we would suggest that children with mild hearing loss are going to be at risk if they're not wearing their hearing aids. They don't accrue that nice benefit of audibility that you're providing them. And one last slide. I want to point out that duration of fit also matters. Here we have plotted those longitudinal growth curves again, but these are little ones who were fit below six months of age and these greater than 18 months of age. A couple things are going on here. First of all, there's a significant effect of age at fitting. Early fitting is better. That confirms that what we're doing with newborn hearing screening matters. But notice the groups really spread it too and then they kind of cluster together and their differences are no longer significant here. What's going on? Well, what's going on is that the early fit children perform in the average range throughout the range. So their learning isn't as steep, but they aren't behind. Whereas our kids fit later are behind and they're playing catch-up this whole time. The good news is by six, they showed a pattern of closing the gap. However, it still suggests that early fitting puts children in a better developmental circumstance. I've heard Bruce Tomlin say it's like people who run a marathon, those who get to start at the front of the pack have an advantage. We believe these early fit children have an advantage of being at the front of the pack developmentally. But it does suggest that later fit children can catch up and that's good news for parents whose children are later identified. So early fitting, best outcome, later fit shows some promising growth once they're aided and use their aids longer. So a summary, early hearing aid fitting, your efforts to optimize audibility and consistent hearing aid use. All three are bolstering the consistency of children's auditory experience with the language and that is positively influencing their outcomes. So let's think for a moment about what family factors were related to this hearing aid use issue. First of all, I mentioned that socioeconomic status or maternal education mattered. That's not really a variable we may be able to change, but it may mean we need to work with those families in different ways in our counseling approach. These factors, however, were pointed out by Karen Munoz. She found significant correlations between hearing aid use and how much frustration, confusion, or lack of confidence parents were reporting. So higher levels of these left hearing aid use. Furthermore, parents who did not perceive that the hearing aid was benefiting their children had lower use. And we could imagine that for parents of children with mild hearing loss, they see them responding to lots of sounds without amplification. So we need to handle with care how they come to understand the benefit from the hearing aid. And we think some of our results that I've shown you already might be helpful in that regard. So I want to mention that more efficacious parents, those where we've addressed their frustration, confusion, or lack of confidence are going to have increased hearing aid use in their children. So we want to spend our efforts there. Here's an issue of a challenging little 24-month-old where the parent reported that hearing aid use was difficult all the time. He's tired and grabbing his hearing aids. The audiologist said, Jesus, family can't keep the hearing aids in. He doesn't resist putting them in, but he's constantly pulling them out throughout the day. And this is challenging because the family often gives up. Well, let's empathize with a family. If they're already ambivalent, they're not sure that their child is gaining that much from the hearing aid. It's really hard to persist when the infant throws up roadblocks. So we like to use this consistency rating in addition to data logging. Data logging tells us how much, but this tells us something different. This is somewhat like a routine-based interview. And I'm only showing you part of the interview, but you can get the full scale on our website. That is listed right here. So the parent is asked to indicate never through always in the car, daycare, meal time, and so forth, how consistently is your child wearing the device? This child only had four hours of use on data logging, and you can see there are situations where they don't even try, and a number of situations where they're rating them as sometimes. So we might want to begin with the sometimes and try to increase their use before trying to work with more struggles in these rare or never circumstances. Here's another child. This was a child with moderate... Oh, I mentioned that child four hours a day. Yeah. Then there was a 12-month-old with moderate hearing loss who was wearing it eight hours a day. And here you see a different pattern on the routine-based interview. There's sometimes categories, often and always. Furthermore, this parent was reporting that they did daily listening checks. They used three types of retention, odal clips, Hanna Anderson cap, and sometimes to pay tape. So we can imagine that this parent was much more actively engaged in managing the amplification and knowing when the child was without sound. We definitely need parents to be empowered with this information. So we have more of this scenario, and we can try to work with often to always and sometimes to often. This use consistency across situations, I'll just point out, we looked at our data in the big study and found that, particularly for children in the zero to two range car was really challenging. So not very many parents reported that they always used it in the car. And that got better with age group. So there are very few reporting rarely in the five to seven year age group. But notice in that zero to two, it's really spread. And the same was true for public and for day care. So it's important to ask about situations. We found that situations in which the child can't be closely monitored. That was more challenging for families and they need more support there. So obviously you want to give them access to the a variety of possible resources for retention. And we find those may need to change over time. Something might work for a while and then a toddler needs a different approach. I did some studies of what were the toddler or young child issues that were creating barriers. Some of it's just developmental discoveries. I put feet here because around 14 months when they start walking, it's a very fun game to run away and laugh and pull out your hearing aid. Furthermore, we know around 12 months of age, kids get causality or cause effect. And they discover if I pull it out, adults come and pay a lot of attention. So these developmental barriers, it's not always just about the parent. I like to say it's bi-directional. There is a baby or a young child in the mix that's creating barriers. With parents, I like to emphasize the possible. Look how clever that is. He's discovered that pulling out a hearing aid gets your attention. So maybe a way we can adapt this is to be pretty neutral and not give a lot of fuss and attention. Put it in matter-of-factly. Provide information on different ways they can respond. Calm reinsertion. Distracting the child. Offering the child reassurance and getting them involved quickly in another activity. And I think it's really critical that we help parents talk with other parents who did overcome these challenges like infant development or other infant behavior. By other infant behavior, oh, this was the family I worked with, they needed that Hannah Anderson bonnet from 12 to 16 months. And then the child gave it up and left her hearing aids alone. So things do get better over time and it helps to reassure parents this might be temporary. Also, we found that parents reported particularly of the younger group, they reported more issues with child state that were barriers to hearing aid use. And by child state, I mean fussy, sick, having a tantrum. And interestingly, what our research showed was that children with docile temperaments are better at keeping their hearing aids in. That's not a big surprise. But when the child's fussy, cranky, ill and they have a feisty temperament, that can be really a challenge for parents. So we like to give a temperament questionnaire and understand that infant's temperament and use that in our counseling regarding child state. But many times parents are making a good decision when child state is on overdrive. But we want to help them know that they should try again quickly or soon and not leave it out for hours. What about offering strategic supports then? As I mentioned for infant state reinforce that this is temporary. You've got a spirited child and so we need to make some accommodations. But this too will pass. Also help parents commit to reestablishing device use practices just as soon as possible. But we as audiologists, parent infant teachers, preschool teachers and so forth need to understand this is bidirectional in its challenges. There is a child in the mix that's creating challenges for the parent. And so we want to support them to trust their gut many times and yet be persistent. There's a fine line between knowing your child and trusting your gut and still being persistent. I remember one mother who said to me, I just needed to be more stubborn than my child. And in doing so, she got her child to full-time use. Simply reinforcing the hours or it must be full-time can be guilt-provoking and may not be sensitive to some of these challenges we have from the child themselves. I had one wonderful mother in the study who said, what's the point of my child wearing the device if I haven't checked it every day? And they're not getting good audibility. Boy, that was a quote worth keeping. And it suggests that parents can be really great partners in monitoring audibility because their audiology appointments may be very spread. And so we need SLPs, other providers as well as the audiologists to make sure parents are transparent and on this issue of monitoring. We make sure parents are very skilled at using the Ling Six Sound test with their children every day so they can notice when audibility is different. Maybe there is an ear infection. Maybe a battery has died. Although they can refer to the hearing aid indicator light, they shouldn't rely on them. I have indicator lights blinking saying it's fully powered but it could have distortion or broken microphone, air mold blockage, a variety of things. We always give parents a kit with these devices and ensure that they're checking batteries and cleaning the device regularly. And I followed children in one study out to five years of age and I have to say by the time they got into preschool parents started getting complacent and around the device to hear if it whistled or not in order to check it. We really want to help them not get into that habit but rather listen to the device in order to detect any distortion. Special issues with children with the mildest losses is being sensitive to the fact that they might perceive their child has limited difficulty and really hears quite well and our labels don't help either. Haggard and Primus in 99 showed that parents with labels like mild or moderate they consistently underestimated the impact of the child's hearing loss on development. And in contrast when they listened to a simulation of the hearing loss they understood the potential magnitude of the risk using simulations that demonstrate the hearing aid benefit is highly recommended. Also Karen Anderson developed a nice task of early listening function where parents can be involved at home in monitoring auditory development and we do recommend using not mild hearing loss but potentially educationally significant hearing loss and help parents tie that child's listening to optimizing their language development perhaps showing them some of the slides I shared with you that more use and good outability contributes to really good language over time. That's the optimistic part of my message today. Now last little section we also think that there's some what I call differential vulnerability meaning some parts of language learning might be harder than others for a child who has who is hard of hearing. Why? Because hearing loss reduces opportunities to perceive elements that are subtle in the input. So my example is from this sentence in our cookies. That s on the verb is going to be especially hard to hear if the bandwidth is limited or speech is fast it's in the middle of the sentence it loses amplitude so does the plural s on cookies. So that predicts that grammar might be more at risk than maybe vocabulary or social pragmatic aspects of language development. And so we wanted to test this hypothesis and so we developed an elicitation task we actually created these DVD movies that would elicit multiple productions of all these different word endings so that we could look at how our children were faring in their grammatical or morphological development. This was kind of a fun task because of child actors and DVD scenarios. So I'm going to tell you the big picture here what I have again now I have plotted our children by degree of hearing loss mild, moderate moderate severe and here's our hearing children and these are plotted by these scores relative to the hearing children and what you're going to notice is the scores for vocabulary and concepts what we're calling semantics. So they are more depressed as hearing loss increases but not nearly as rapidly as we see for the grammatical area and look at our mild children one standard deviation down moderate severe there are almost two standard deviations down so we're not saying vocabularies never at issue we're saying that there's greater deficits in the grammatical area which suggests we want to really monitor those skills and perhaps provide more intervention around those areas. One more so our conclusion is these children who are hard of hearing have some areas of language learning that are particularly challenging because of the ways they may be able to access spoken language input. I just want to quickly mention this because it's kind of fun I think you'll enjoy it we've also been interested in are they vulnerable in social areas so irony or sarcasm I must admit sometimes I miss sarcasm in the message it's very dependent on what we hear but we provided the children with nine pictures recorded stories and we presented them in so they could look and listen and then the child answered questions that required them to interpret or reason about that input so here's one of the stories the boy pair was very long so his dad said that he would cut it for him I can give you a good haircut he said and here's the second part but the dad cut off almost all of the boy's hair and it was all a mess when she saw the boy the mom said to the dad you sure gave him a good haircut and then the child asked questions like what did the mom mean when she said that so they need to interpret the sarcasm so last I'll show you here we have our hearing kids they are mild, moderate, moderately severe this is so interesting the mild kids look almost identical to the moderately severe and they are different from both moderate and hearing what does this mean we're suggesting that there might be a sweet spot the children with moderate loss get a lot of attention because it's significant enough that the children with mild loss may not be wearing hearing aids or may not be given services and so they're functioning like this group over here moderately severe and we think that's an issue that's a concern and again amplifies my point we're seeing across a number of areas the emergence of this sweet spot in our data with the mild children performing less well than we think they should and that suggests to us the need for vigilance so that brings me to my last comment maybe we need to ask some different questions as well these kids are learning in complex listening environments and we don't know much about that I love this acoustic ecology that was McClellan had all I think Canadians that they say in spite of this crucial role of trouble in assessing the input we just don't know much about how the acoustic ecology in child care and educational settings is influencing the experiences and the learning of children in those settings one of my colleagues at Boys Town, Donna Lewis is starting research that tries to simulate a classroom she can control the level of noise and vibration and have multi-talker conversations going on in here and monitoring children's outcomes I think that's very clever and an important future step so that brings me to the end I would conclude that children with mild and mild moderate hearing loss are at risk for language delay there are some problems of qualifying them by just comparing them to standardized test norms but they're two needs especially in noisy environments we think it's relevant to compare them to their schoolmates it's also important to consider how they're doing in noise and then finally your efforts to optimize out abilities majorly important I applaud you it's giving children linguistic access and promoting better development and finally the parents use might need some individualized support I'd recommend this routine based interview and that you snag that from our website and that we find ways to tie hearing aid use to language and literacy outcome in very practical ways and ensure that these families are talking with other families in order to get support so I mentioned our website we have a lot of resources on there including access to lots of articles we published and kind of a parent summary of some of the main conclusions from our study well I realized I left just a few minutes for questions and I went through that pretty quickly so I hope I was clear I did want to show you the village that's been conducting this work lots of different people in different disciplines and it's been quite a pleasure to work with all of them this gentleman right here directs the grant with me that is Bruce Tomlin so I'll go back to our website so you have that and I'll stop and thank you again and ask for questions we usually I'm going to wait for a few seconds because I have to look for the microphone to be unmuted for somebody to chat this is amazing the information that you summarized just under an hour is so thoughtful and thought provoking and I appreciate it myself so I'm not getting any questions just yet if there aren't any I sure hope people found this to be beneficial in your practice I certainly have and I know that I usually get email feedback from people about the presentation there seems to be a level of shyness in this format but Mary Pat, thank you so much for taking the time and staying out of the cold in Nebraska we have the exact same weather here by the way and I'll be communicating with you somehow in the near future so thank you everyone and we're going to end now