1. Components of a Successful Early Intervention Program Arlene Stredler Brown, CCC-SLP, CED Colorado School for the Deaf and the Blind University of Colorado – Dept. of Speech, Language, Hearing Sciences Marion Downs Hearing Center @ University of Colorado Hospital

2. The fundamental question is: Do our universal newborn hearing systems improve long-term outcomes for children?

3. And the answer must address: Collecting data Collecting data Single point of entry Single point of entry Using family-centered practices Using family-centered practices Parent participation Parent participation Using D/HH role models Using D/HH role models Measuring child outcomes Measuring child outcomes Selecting a communication approach Selecting a communication approach Accommodating cochlear implants Accommodating cochlear implants Assessing functional auditory skills Assessing functional auditory skills Children with minimal hearing loss Children with minimal hearing loss Sign language instruction Sign language instruction Using program consultants Using program consultants Programs for children from minority cultures Programs for children from minority cultures

4. Collecting Data to Support a Program Individual child data: Baserate of childs developmental skills: communication, language, functional auditory skills, phonologic skills, speech intelligibility, cognitive skills, other developmental domains Individual parent data: Parents needs, characteristics of parent-child interaction Aggregate program data: To measure program outcomes To support program initiatives

5. How can we collect data? Checklists & surveys Videotape analyses Parent-administered protocols Standardized tests

7. Single Point of Entry into Early Intervention Issue: 74% of the children have their hearing loss diagnosed by 3 months of age; the average start of early intervention is 5 months of age. How can we maintain, and lower, the age at which children start early intervention? Parents request service coordination from a person who can answer questions related to hearing loss and provide emotional support specific to issues related to hearing loss Collecting Information: CHIP Facilitator Survey, CHIP Parent Survey Evaluating the Data..

8. Information Shared with Families CHIP Parent Survey, 2003 Information requested by parents: Education: Hearing Loss97% Education: Hearing Loss97% Education: Comm. Approaches97% Education: Comm. Approaches97% Websites, books, videos95% Websites, books, videos95% Preparing for the IFSP87% Preparing for the IFSP87% Education: Amplification/tech82% Education: Amplification/tech82% Connecting w/ agencies69% Attending audio. Evals51% Education: Law46% Connecting w/ D/HH role model41% Family Advocate18%

9. Single Point of Entry into Early Intervention Evaluating the Data: Many states that depend solely on the Part C service coordinator have children starting early intervention > 6 months of age Program Modifications: CIHAC develops guidelines for entry into early intervention

10. Transition from Diagnosis to Early Intervention Audiologist Confirms Hearing Loss Hearing Resource Coordinator is Contacted Contacts family Initiates data management Contacts local agencies

11. Using Family-Centered Practices Issue: More early interventionists need training to utilize family-centered strategies Collecting Information: CHIP Facilitator Survey Evaluating the Data: 5 true-false questions addressing implementation of family-centered (versus child-centered) practices: 78% received a score of 70% or higher on these questions. 5 open-ended questions querying the use of family- centered practices: 58% of the facilitators supplied answers indicating they were implementing family- centered practices

12. Using Family-Centered Strategies Program Modifications Consultant hired to provide technical assistance on use of family-centered strategies CHIP Clinical Training Manual Early Intervention Illustrated Series

13. PRIMARY PROCESSES START…. Family Issues GOAL…. SECONDARY PROCESSES Child Outcomes feelings information expectations opinions R a p p o r t T r u s t R e s p e c t communication approach specific skills

14. Family-Centered Strategies The Home Team The early interventionist helps parents to gain confidence: identify parents strengths, acknowledge acquired skills Parents have the responsibility for their decisions Continually monitor the pace & content of the intervention: at the time of diagnosis, at 3 month intervals, during transition to preschool Produced by: CHIP, CSDB, Boys Town

15. The Art & Science of Home Visits.. Knowledge and skills of the early interventionist Communication & language development Child development Potential impact of hearing loss Communication approaches Amplification & listening devices Assistive technology Values & culture Tools of the Trade Produced by: CHIP, CSDB, Boys Town, NMSD, SKI*HI, NCLID

16. Rubric for a Home Visit Colorado Home Intervention Program (CHIP) Colorado School for the Deaf and the Blind (CSDB) Copyright 2003

17. Parent Participation Issue: The most successful children are those with high levels of family involvement; maternal communication skill predicts early reading skills, higher language skills, fewer behavior problems Collecting Information: Moeller (2000), Calderone (2000) Evaluating the Data: Moeller, 2000 112 children with mild to profound hearing loss No evidence of major secondary disabilities Variety of communication modes Calderone, 2000 28 children with prelingual hearing loss moderately-severe - profound tested at 45-88 months of age

18. Parent Participation Program Modifications Support family-centered intervention strategies Hire and train sign language instructors Assure access to parent-to-parent connections (Families for Hands & Voices) Information Support Leadership Train D/HH role models..

19. Deaf/Hard of Hearing Connections Training on how to work with families Providing families emotional support Managing communication Deaf Culture Hard of Hearing issues Coordinating with the early interventionist Providing resources

20. Child Outcomes Issue: Children have many skills WNL for their chronological age. However, when specific skills are evaluated, there is evidence that some elements of language development are more advanced than others. Collecting Information: FAMILY Assessment; Minnesota Child Development Inventory (MCDI); Language Sample Analyses Evaluating the Data 352 deaf and hard of hearing children Children assessed on 1 to 9 occasions Total number of assessments = 725

21. Child Outcomes Evaluating the Data Chronological Age: 6 months - 6 years;3 months Mean = 34 months Cognitive Ability: Estimated to be within the normal range (MCDI data) Hearing Loss: Bilateral, mild to profound Parents: Normal hearing, English is primary language Communication Approach: Full range of approaches MCDI: Selected items examined from 2 subscales: Expressive Language, Comprehension/Conceptual (Receptive Language)

22. Results: Proportion of Delay Non-Verbal1.14 Pre-Literacy1.05 Colors/Numbers.97 Rote Language.96 Early Communication.87 Concept Vocabulary.79 Early World Knowledge.76 Cognitive-Linguistic.71 Grammar.66

23. Child Outcomes Evaluating the Data: SALT: 219 children selected in the following age groups (plus or minus 3 months) 3 years old (n = 90) 4 years old (n = 55) 5 years old (n = 49) 6 years old (n = 24)

24. Results: Total Number of Utterances Chronological Age (years) # of Utterances

25. Results: Mean Length of Utterance (words) Chronological Age (years) MLU in Words Family-Centered Intervention: Proven Strategies to Assure Positive Outcomes

26. Child Outcomes Program Modifications: Raise Expectations: Review expectations of facilitators and parents Intensity of Services: Consider increasing frequency of services when children are 24-36 months of age Extending Parent-Centered Services: Consider continuing parent-centered intervention while children are in preschool Proficiency of Staff: Increase CO-Hear Coordinators time to provide mentoring to facilitators

27. Selecting a Communication Approach Issue: National debate on the optimal or correct communication approach Collecting Information: Multiple measures on the FAMILY Assessment Evaluating the Data: Yoshinaga-Itano, et al, 1998; Mayne, et al, 2000)

28. Selecting a Communication Approach No significant effect of communication mode on total language quotient In an analysis of expressive vocabulary development, mode of communication did not have a significant correlation with vocabulary development In a study of receptive vocabulary development, after controlling for cognition, mode of communication was not significantly associated with the number of words children understood

29. Selection of Communication Approaches Program Modifications 50% of families change the approach they use at least once during the 3 years in early intervention CHIP philosophically supports and offers all communication approaches – Is this a trend? Collaboration (versus competition) with other programs

30. Cochlear Implants and Communication Approach Issue: Perceived concern (parents, physicians, audiologists) that use of sign language after implantation will limit development of oral communication Collecting Information: FAMILY Assessment; MacArthur Communicative Development Inventory, Spontaneous Language Sample Evaluating the Data 54 deaf children who received cochlear implants English is the primary spoken language in the home Hearing parents Implanted by 5 years of age

31. Evaluating the Data.. Age at implantation Range = 13 months to 5 years;1 month Mean age = 31 months Simultaneous Communication Participants: n=29 Selected children who signed in > 50% of utterances in pre- implant tape No additional disabilities that could interfere with language development

32. Results: Use of sign & spoken vocabulary (MacArthur) Months Post Implant % of Words

33. Results: Use of sign & spoken vocabulary (Language Sample) Months Post Implant % of Words

34. Cochlear Implants and Communication Approach Program Modifications: Encourage maintaining communication approach used before implantation while new skills are acquired Support families choice of communication approach

35. Development of Functional Auditory Skills Issue: Initial checklist had few items (14) which did not reliably document progress nor did it provide a teaching guide for intervention Collecting Information: FAMILY Assessment; Checklist of Auditory Skills Evaluating the Data Assessment tool does not provide measurable outcome data Program Modifications Functional Auditory Performance Profile - FAPI (Stredler-Brown & DeConde Johnson, 2003)

36. Children with UHL Issue: Children with UHL are now being identified on a regular basis through newborn hearing screening programs and efficacy data is needed to development a treatment protocol Collecting Information: FAMILY Assessment Evaluating the Data.. n = 30 children 2 (7%) progressed to bilateral within first year of life 2 (7%) later diagnosed with bilateral losses that apparently were present from birth One mild (30dB) in poorer ear One moderate, low frequency loss with normal high frequency hearing

37. Children with UHL Evaluating the Data n=15 children examined across measures and time Considered assessments after 12 months of age No additional disabilities Number of children with language delays Delayed = 4 (27%) Borderline = 1 (7%) Program Modifications Implement statewide program to provide information to parents and professionals Provide developmental screening to monitor development Enhance service delivery through funding from the Marion Downs Hearing Center NCBDDD @ CDC giving this topic consideration

38. Oral Communication Consultant Issue: Early interventionists request technical assistance for children whose parents have chosen oral/aural communication (including simultaneous communication) Collecting Information: CHIP Facilitator Survey Evaluating the Data Facilitators send evaluation of site visit Program Modifications OCC position co-funded by private AVT program and CHIP Future: Evaluate auditory skills, phonologic repertoire, speech intelligibility of children receiving this technical assistance

39. Sign Language Instruction Program Issue: Children who sign are developing expressive sign skills at a slower rate than their chronological age Collecting Information: SALT transcripts Evaluating the Data: Parents sign skills are at or slightly above the sign level of their child Program Modifications Enhance delivery of sign language by assigning a sign language instructor Provide up to 6 hours/month of home-based sign instruction from a native signer (e.g., D/HH adults, CODAs) Develop curriculums, including the Integrated Reading Project (IRP)

40. Consultation Services Issue: Early interventionists (ToD/HH, SLPs, Audiologists) do not always have sufficient information to diagnose and accommodate needs related to additional disabilities. Collecting Information: CHIP demographic data Evaluating the Data 40% of children, B-3, have additional disabilities 30% of children, school-age, have additional disabilities 12% of children, B-5, have dual sensory impairments Parents level of emotional stress may require intervention Program Modifications Specialty consultants are contracted to provide training, technical assistance, home visits (PT, mental health, functional vision)

41. Participants & colleagues supporting this work are: The parents of children enrolled in early intervention programs in Colorado 10 Regional Colorado Hearing Resource (CO-Hear) Coordinators 115 CHIP Facilitators – the interventionists who do the work on the front-lines Christie Yoshinaga-Itano, Allison Sedey, Karen Carpenter and members of the research team at CU- Boulder Colorado School for the Deaf and the Blind (CSDB) Colorado Department of Education MCHB, NIH, CDC Colleagues in other states and countries who ask the questions that direct us to find the evidence

42. For more information: Check the CHIP webpage at: www.csdb.org