Language Outcomes, Growth, and Predictors of Success: A Multi-State (NECAP) Perspective WREIC June 16, 2017

Presenter Allison Sedey, Ph.D., CCC-SLP, CCC-A Allison.Sedey@Colorado.edu University of Colorado-Boulder Colorado School for the Deaf and the Blind

Additional Author Christine Yoshinaga-Itano, Ph.D. University of Colorado-Boulder Christie.Yoshi@Colorado.edu

Acknowledgements Early interventionists in NECAP states Participating families Assessment Coordinators: Clare Neville, Anna Clark, and Mallene Wiggin A long list of SLHS undergraduate and graduate student employees who assisted in scoring test protocols and data entry

Today’s Topics Brief description of NECAP Sample characteristics Factors associated with more successful language outcomes Language outcome data over time Strengths and limitations in specific language skills

What is NECAP? All families are participating in NECAP National Early Childhood Assessment Project CDC-supported project examining language outcomes at a national level Birth to 3 Children who are deaf or hard of hearing

Motivation for NECAP 2007 JCIH Position Statement (Goal 6 of 2013 Supplement) “All children who are D/HH should have their progress monitored every 6 months from birth to 36 months of age, through a protocol that includes the use of standardized, norm- referenced developmental evaluations”

Motivation for NECAP Using a common set of instruments across states allows us to: Examine outcomes nationally (rather than from a single program or state) Improve the validity of outcome results by increasing sample size Include children who are participating in different amounts and types of intervention

Demographic Characteristics of Participants with Bilateral Loss English, Spanish and/or ASL used in the home With and without additional disabilities All degrees of hearing loss Demographics that follow based on 448 children in predictive study Individual studies vary slightly (by a few percentage points)

Participant Characteristics: EHDI Guidelines Age at… Mean (mos) Identification 4.1 Intervention 7 *58% of children met the EHDI 1-3-6 guidelines

Participant Characteristics: Degree of Hearing Loss % Mild 35% Moderate 22% Moderately severe 15% Severe 8% Profound 20%

Participant Characteristics: Type of Amplification % None 11% Hearing aid 68% Cochlear implant 16% Bone conduction aid 5%

Participant Characteristics: Mother’s Level of Education Highest degree completed % of primary caregivers Less than HS 13% High school diploma 38% Vocational or Associates 20% Bachelor’s degree 22% Graduate degree 7%

Participant Characteristics: Communication Mode Communication mode used with child by family % of primary caregivers Primarily spoken language 74% Spoken only 30% Very occasional sign used 44% Spoken + sign language 22% Sign only 4%

Assessment Instruments

Assessments Minnesota Child Development Inventory 12 months to 6 years Expressive Language and Language Comprehension subscales MacArthur-Bates Communicative Developmental Inventory 8 to 30 months Expressive vocabulary subscale (in spoken and/or sign language)

Assessment Characteristics All 3 of the assessments are: Standardized Norm-referenced (normed on children who are hearing) Parent report

Minnesota Child Development Inventory Parents respond “yes” or “no” to a variety of statements about their child Examples: “Has a vocabulary of 20 or more words” “Uses the word ‘not’ in sentences “Expresses likes and dislikes in words”

MacArthur Bates Communicative Development Inventory List of 680 words divided into semantic categories (toys, food, action words, descriptive words, etc.) Parents indicate words their child produces In spoken language In sign language

Determining Language Quotient Language Age/Chronological Age x 100 If LQ = 100, Language Age = CA If LQ < 100, Language Age < CA If LQ > 100, Language Age > CA Average Range Minnesota: LQs of 80+ MacArthur: LQs of 75+

Three Separate Studies Titles of the 3 studies “Predictive Analysis” “Growth Analysis” “Item Analysis” What is different Number of participants Demographic characteristics (but very similar across studies)

Predictive Analysis: MacArthur Expressive Vocabulary

MacArthur Predictive Analysis: Participant Criteria Bilateral, pre-lingual hearing loss (all degrees -- mild to profound) No diagnosis of auditory neuropathy English or Spanish is written language of the home Children with and without additional disabilities included

MacArthur Predictive Analysis: Number of Participants 448 children Child’s most recent assessment used Chronological age Range = 8 to 39 months Mean = 25 months

States Represented in Predictive Analysis Arizona California Florida Idaho Indiana Maine North Dakota Oregon Texas Utah Wisconsin Wyoming

Predictors of Better Vocabulary Outcomes: Multiple Regression Significant predictors of MacArthur expressive vocabulary quotient Presence of additional disabilities Meeting EHDI 1-3-6 guidelines Higher mother’s level of education Lesser degrees of hearing loss Parent who is deaf or hard of hearing Quotient decreases with age so gap between CA and Language Age is widening over time

Group Comparisons: Children with no additional disabilities meets Mild-Mod

Relationship of vocabulary quotient and chronological age

Group Comparisons: Vocabulary Quotient and Chronological Age < 24 months 24+ months

Exploring the widening language gap Exploring the widening gap between chronological age and language age When does the gap begin? How much does it widen over time? Which general areas of language demonstrate the biggest gap? Which specific language skills contribute least and most to the gap?

Growth Analysis: Minnesota Language and MacArthur Expressive Vocabulary

Growth Analysis: Participant Criteria Bilateral, pre-lingual hearing loss (all degrees -- mild to profound) No diagnosis of auditory neuropathy English is written language of the home No other disabilities that would affect speech or language development

Minnesota CDI Growth Analysis: Number of Participants/Assessments Outcomes are a combination of cross- sectional and longitudinal data 457 children Assessed on 1 to 5 occasions Total assessments = 739

MacArthur CDI Growth Analysis: Number of Participants/Assessments Outcomes are a combination of cross- sectional and longitudinal data 634 children Assessed on 1 to 5 occasions Total assessments = 1,066

States Represented in Language Growth Analysis Arizona California Florida Idaho Indiana Maine Minnesota New Mexico North Dakota Oregon Texas Utah Wisconsin Wyoming

Growth Analysis: Participant Characteristics Chronological age Range = 12 to 35 months Minnesota mean CA = 24 months MacArthur mean CA = 23 months

Minnesota CDI: Expressive Language Subscale

Minnesota CDI: Language Comprehension/Conceptual Lang

MacArthur-Bates CDI: Expressive Vocabulary

MacArthur-Bates CDI: Expressive Vocabulary Size – 50th Percentile

Item Analysis: Minnesota Expressive Language and Language Comprehension

Item Analysis: Participant Criteria Bilateral, pre-lingual hearing loss (all degrees -- mild to profound) English is written language of the home No other disabilities that would affect speech or language development

Minnesota CDI Item Analysis: Number of Participants/Assessments Outcomes are a combination of cross- sectional and longitudinal data 535 children Assessed on 1 to 6 occasions Total assessments = 935

Minnesota CDI Item Analysis: Participant Characteristics Chronological age Range = 12 to 35 months Mean = 24 months

Primary Contributing States (each > 5% of the database) Colorado – 39% Idaho – 20% Arizona Indiana Texas Wisconsin

Secondary Contributing States (< 5% of the database) California Florida Maine Minnesota New Mexico North Dakota Oregon Utah Wyoming

Minnesota CDI Item Analysis: Results: Language Quotients Expressive Language Median = 95 LQ of 80 and above = 79% Comprehension and Conceptual Language Median = 87 LQ of 80 and above = 65%

Determining Item Age Level Group children into 3-month age brackets (e.g., “12 month group” = 12 to 14 months) Find the first age group at which 75% of the children achieve a given item These same procedures followed in the test’s normative sample

Linguistic skills at age level Non-verbal communication “Points” Asks for drink or food using words or sounds Early verbal communication (first 20 to 40 words) Uses at least 10 words Greets people with “hi” or similar expression

Linguistic skills at age level Basic comprehension Follows simple instructions Understands the meaning of “up” and “down” Rote language Says/signs “please” and “thank you” Greets people with “hi” or similar expression

Linguistic skills: Mildly delayed Comprehension of early conceptual vocabulary Understands what “off” & “on” mean Understands what “open” & “close” mean Concrete, single word utterances Names a few familiar objects in picture books Uses 50 or more different words

Linguistic skills: Moderately delayed Early number concepts Understands “one” and gives you just one when you ask for “one” Use of first pronoun Says/signs “mine” or “my”

Linguistic comprehension skills: Severely delayed Prepositions Understands the meaning of at least 3 location words (“in,” “on,” “under,” etc.) Complex comprehension Follows 2-part instructions

Linguistic production skills: Severely delayed Pronoun use Use of negative forms (not, don’t, won’t, can’t, etc.) Conceptual vocabulary “Points to/names the bigger of 2 objects” “Expresses feelings in words” Says/signs when something is heavy

Linguistic production skills: Severely delayed Grammar Uses plural words (e.g., “girls,” “cats”) Asks questions with ‘what’ or ‘where’ Uses the words “a,” “an,” and “the”

Summary Better language scores are associated with: Absence of additional disabilities Meeting the EHDI 1-3-6 guidelines Higher maternal level of education Less significant degrees of hearing loss Parent who is deaf/hoh

Summary One of the strongest predictors of language quotients is chronological age As CA increases, Language Quotient decreases

Summary As language demands increase over time, gap between CA and Language Age widens Divergence from age expectations starts at: 25 mos for general, surface structure expressive language 20 mos for cognitive-linguistic skills 16 mos for expressive vocabulary

Summary By 35 months of age the gap between language age and chronological age is: 7 mos for general, surface structure expressive language 8 mos for cognitive-linguistic skills 12 mos for expressive vocabulary

Summary The majority of 12- to 18-month level language items are demonstrated at or close to on schedule Children who are d/hoh demonstrated delays on almost all language items at or above the 21-month level

Summary Beginning at 19 mos, hearing children produce 35 to 40 new words per month Beginning at 19 months, children who are deaf or hard of hearing average 15 new expressive words per month It is important for parents and interventionists to keep typical development in mind when assessing progress and setting goals

Summary Average language scores for a group of children from birth to 3 typically underestimate the skill level of children below 2 years of age and overestimate the skills of children above 2 years of age Research and accountability data for this age range should divide the children into two age groups