1. The impact of language underperformance on social and communication functioning in children with cochlear implants Jareen Meinzen-Derr, Susan Wiley, Sandra Grether, Holly Barnard, Julie Hibner, Daniel Choo, Laura Smith

2. Background Social and communication functional skills are essential for independence –Skills require language Research in deaf/hard of hearing limited –“Functional performance” commonly used to describe functional hearing Literature supports language acquisition, but often omits practical benefits of language

3. Objective To assess how language levels impact social and communication functioning in young children with cochlear implants Does having a language level that is lower than your cognitive abilities impact your daily functional skills?

4. Eligibility Balanced regarding degree of hearing loss and age 3-6 Years Bilateral hearing loss prelingual Nonverbal IQ >40 NVIQ 40-79 NVIQ >80

5. Assessment Tools Language Assessment: –Preschool Language Scales -5 Neurocognitive Assessment: –Leiter International Performance Scale-R, Behavioral Rating Inventory of Executive Function Functional Assessment –Pediatric Evaluation of Disability Inventory –Vineland Adaptive Behavior Scales

6. Outcome Measure Pediatric Evaluation of Disability Inventory Comprehensive standardized measure of essential daily functional activities –197 discrete functional skill items –Self-care, mobility, social function –Standard (mean 50+10) and Scaled Scores Useful in treatment planning and identifying specific areas where assistance is needed

7. Social Function Domain Comprehension Word Meanings Comprehension of Sentence Complexity Functional Use of Communication Complexity of Expressive Communication Problem-resolution Social Interactive Play (adults) Peer Interaction (child of similar age) Play with Objects Self-Information Time Orientation Household Chores Self-Protection Community Function

8. Outcome Measure Vineland Adaptive Behavior Scales Reflects the individual’s personal and social skills as he/she interacts with environment –383 items –Communication, Daily living skills, socialization, motor skills –Standard scores (mean 100+15) Can measure adaptive behavior in different subgroups

9. Defined Language “Gap” LANGUAGE:COGNITIVE RATIO IQ = 100 LANGUAGE = 80 80/100 or (0.80*100)=80 Language abilities relative to cognitive abilities >50% have a language to cognitive ratio <80 Receptive Language standard score Nonverbal IQ standard score

10. Characteristics n=41 Mean Age of study (months)58.5SD 13 Male2049% Etiology of HL unknown1844% Born premature37.3% Duration of Implant in months31.115.7 Bilateral CI2458.5% Maternal education HS/GED Some college College Post graduate 7 15 8 11 17% 36.5% 19.5% 27% Insurance Private Public Combo 16 17 8 39% 41.5% 19.5% Income <$50,0002050%

11. Functional Skill Outcomes Vineland Adaptive Behavior Scales (mean of 100) Pediatric Evaluation of Disability Inventory (t-score of 50)

12. Vineland Adaptive Behavior Scales (mean of 100) Pediatric Evaluation of Disability Inventory (t-score of 50)

13. Communication and Social Function among Children with CI VABS COMMUN.βP-VALUEPARTIAL R 2 TOTAL R 2 NONVERBAL IQ 0.250.0340.315 RECEPTIVE: IQ 0.340.0030.2660.581 WORKING MEMORY -0.420.0090.0660.647 SES SCORE 2.310.0020.1060.753 PEDI SOCIAL βP-VALUEPARTIAL R 2 TOTAL R 2 NONVERBAL IQ 0.48<.00010.292 RECEPTIVE: IQ 0.370.0020.1210.413 PREMATURE -4.160.0460.0560.469 UNKNOWN ETIOLOGY -7.70.0580.0520.521 NS: receiving therapy, aided SRT/SAT, duration with implant, age of implant, mom education

14. Adjusted mean PEDI social function scores (adjusted to scale of 100) p=0.007

15. Adjusted Mean Vineland Communication Scores p=0.008

16. In Summary Low language performance has functional impact on communication and social skills –Impact among a broad range of IQ –Language does not have to be “sub-normal” Strive to meet a child’s potential, but be cognizant of the role sub-optimal language levels Consider interventions specific for improving pragmatic language and social skills

17. What does this mean? Language is directly related to social and communication functioning –Language gap significantly impacts this functioning negatively The gap does not mean below average –It is easy to become “complacent” regarding “normal” language scores Current study includes 0-3y population to determine a developmental profile of children who may need early support

18. 0-3 year old group: Language Gap is not widening with age

19. Already seeing decline in social functioning with increasing age

20. Early relationship between ratio and communication functioning

21. Early relationship between ratio and social functioning

22. Future Directions Pilot augmentative technology intervention trial Children enrolled in the study with a language gap (irrespective of technology use) are eligible for an assistive technology intervention Receive i-Pad with Word Power software (locked down for other app use during intervention period)

23. Future Directions Participation in 6 weeks of weekly aug comm therapy followed by 6 weeks at home and final 6 weeks of therapy Useage of i-pad monitored Language changes pre- to post- intervention measured –Syntax, grammar, MLU 6 weeks intervention 6 weeks home practice 6 weeks intervention Evaluation, language sample

24. Early Qualitative Findings 2 children enrolled: –1 with average non-verbal IQ –1 with below average non-verbal IQ Quick learning noted by both Increased speech production within one session of therapy by child with non-verbal IQ Increased sentence length with better grammar in child with average IQ

25. Thank You Special thanks to Sandi Bechtol, RN Meredith Tabangin, MPH CCHMC Audiology Boys Town National Research Hospital (Mary Pat Moeller & Barbara Peterson) Participating Families HRSA MCHB R40MC21513, March of Dimes #12-FY14-178

26. Extra slides

27. Communication function for cohort

28. Social Function for cohort