TSBVI Coffee Hour: Assessment, Intervention and Outcomes of Young Children with Mild/Moderate Hearing Levels: A Multi-State Perspective & Academic Outcomes and Predictors of Performance in School-Age Children with Unilateral Hearing Loss Ð 8-19-21
>>Sedey: Hello. Welcome, everybody. I see a lot of familiar names in the chat so that is very exciting and hi to all my friends. I will be talking today about children who have mild and moderate hearing loss, both in the state of Colorado and then also children who are part of a multistate study previously called NECAP and currently called oddicy. My center information is here and this talk is coauthored with Christine Yoshinaga-Itano. Today what I will be talking about are outcomes for children who have mild and moderate hearing levels and comparing those outcomes to children who have more significant hearing losses, those children who have moderately, severe, severe and profound hearing levels. We will be identifying some of the strengths and challenges for these children who are hard of hearing with mild and moderate loss and ring some areas to be sure to assess and to focus on in intervention. So I will start with talking about children who are in the birth to three period. And the data from, that I will be presenting comes from a project that was called NECAP which stand for the national early childhood assessment project. And this was a project supported by the CDC together intervention outcomes from states across the United States. So from multiple states. We are currently in a continuation of that project that I know some of you were watching today are part of.  And that project is called ODDACE. After you hear todays a talk, if you have any interest in joining ODDACE and you are not already part of it, I would love to have you contact me and I can tell you more about it. So the birth to three group, we had 719 children.  These children were assessed regularly at six month intervals resulting in each child having anywhere from one evaluation up to seven evaluations over the course of time. All of the children that I will talk about today in this part of the talk are between eight months and 39 months. So essentially in the birth to three period where an assessment called the McArthur comun indication -- communicative development [Student inaudible] Venn or theories are the appropriate instrument to administer. All of these children have bilateral hearing loss and they do not have any additional disability that either their interventionist or their parent thought would interfere with speech or language development. They also all come from homes where the primary language is English. The written language is English. The face-to-face language might be ASL or spoken English. The children reside in 14 different states. These are the states is that they are in. I will let you take a quick moment to identify if your state was involved, which I think for the most part, some seeing the chat, most of you are from the states that are represented here. So just a few characteristics of the participants we will talk about. Relative to the EHDI guidelines, 70 percent of these children had here hearing losses identified by three months of age and 65 percent were in intervention by six months.  And 58 percent met both of those guidelines. They immediate the EHDI 1-3-6 guidelines. We are talking about two-thirds of children identified quite early and in intervention early. As far as communication approach goes, the project included all communication approaches which you can see represented here. The majority use primarily spoken language. Some of those children occasionally use some sign in specific context or with specific words. About a quarter of the children the parent were trying to speak and sign as much as they possibly could as new learners of sign language and then five percent used sign only with no spoken language. That was primarily families where the parent themselves were deaf or hard of hearing. So we will be looking at two different assessments instruments and the outcomes from them. One is the mac Arthur-bates communicative development inventories which a lot of people on this call are familiar with. But essentially for those that aren't, this is an instrument given to a parent.  It is a checklist of sole vocabulary. It is animals, action words, food and beverages, et cetera. And the parent checkoff any words that their child can produce either in spoken language or sign language. So you get essentially a count of the child's expressive vocabulary. The second instrument is the Minnesota child development inventory, often referred to as the CDI. This is a general developmental instrument that looks at a variety of motor skills and social skills. But today we will be specificking looking at two of the subtests. One being expressive language and the other which is called language comprehension did a subset not only understanding of language but also production and in particular, looks at more conceptual language items, more cognitive  linguistic type of skills. The other looks at more wroat characteristics. Parent read a variety of short statements. Things like my child says at least ten word and they circle yes or no for each of them. And the children are given credit regardless of the language they are producing and understanding is in sign language, spoken language, et cetera. So as far as the number of assessments go, because the children were assessed on multiple occasions over time, we have for the Mac Arthur, 717 assessments that makeup the mild and moderate group we will look at. We have a similar number that are in the severe profound group. We don't have as many for the Minnesota because some ar piss Tating states chose to use different developmental instruments instead of Minnesota whereas everybody utilized the Mac Arthur. But we still have approximately 400 assessments in each of the two groups, the two hearing loss groups. So let's take a look at a ciewp willing of areas where we did not see -- couple of areas where we did not see a significance in the groups. The first two pieces of it, which are couple of demographic features, one being the age of the child's hearing loss was identified. And today'ser being the age that they got into intervention. So it is really exciting that in this day, we are not seeing significant differences in that regard based on the child's degree of loss. Because as many of you well know, prior on the advent of newborn hearing screen or the widespread use of newborn hearing screening, children who had mild or moderate loss were identified quite late. It was confusing to parents and sometimes professionals as well because these children could hear in certain context even without amplification if the sound was loud enough and so often quite a bit of time went by before there were any concerns about hearing. So back in the day prior to newborn hearing screening, we would have seen these bars to be way, way higher. Wouldn't even have fit on the access of going up to 15 months. Often children with mild and moderate loss weren't identified when they started kindergarten and had a screening in school. Now we can see that they are identified very early and at the same time as children with more significant loss. And also interestingly, although there really are no significant differences, if anything, the mild to moderate group had a very slight edge in getting into intervention. I am sorry, they were a little teeny bit later with getting into intervention but within a month with the children with more significant losses. Both of groups were comparable in terms of their mother's level of education and I only point -- we wouldn't think  otherwise necessarily but I point that out to say on these factors, age of identification, age of intervention, mothers level of education, these are all factors that we know can impact outcomes. And so if one of the groups was very different in one of these regards, it wouldn't really be a fair comparison to compare them on degree of loss because we wouldn't know if the difference in outcomes had to do say with their mother's level of education or when they were identified. But we don't have to worry about that today because the groups are quite comparable on all three of those factors that we know influence the language development of children who are deaf and hard of hearing. So we will be looking at the outcomes in terms of what we call language quotients. So just to orient you to this number, a language quotient is similar to an IQ or intelligence quotient where you take the language age and you divide it by the child's crop logic age and get a whole number you multiply by 100. So if you see a language quotient of 100 then that means the child's language age is the same as their chronological age. They are scoring higher than you would see for their age and anything below 100 means they are scoring lower for their crop logic age. That is what we will be looking at with the birth to three data are the language data quotients. Here are language quotient as promised. And this is on both the Minnesota and the Mac Arthur. The all assessments in parenthesis means that I am using all the assessments that the child did over time. So child might be represented in here three times. Maybe only once if they only did one assessment. Maybe for our five times. We had the first Minnesota test, the expressive language and then the comprehension or conceptual language test and then we have the Mac Arthur.  The lighter green bars, those are the children who have mild or moderate hearing loss. And the darker blue bars that is the group of children who have anything from a moderately severe loss up to profound. And let me just pause here to say what the definition was to split these groups. So we looked at the children's unaided pure tone averages and the cut between the two groups was at 55 DB for a pure tone average. The mild to moderate had went up to 55 DB pure tone average.  The moderate to severe started at 56 and then up from there. And you can see across all of the different tests that the children who have mild and moderate hearing loss are doing better in terms of their language scores compared to those children who have moderate, severe loss. And looking at this just slightly differently, these are the same assessments, the same two groups, but what these bars represent are the personal of children who are falling within the average range on the test. And you can see there is quite a difference between the two degrees of loss. Where the children with mild to moderate hearing loss are a much higher percentage, have scores falling in the average range. Compared to the children who have moderate or moderately severe hearing loss. So are these differences actually significant from a statistical standpoint? The answer to that question is yes. T-tests were performed on each of the different instruments: Comparing the two groups. Those that have mild to moderate loss, those with more significant loss and in all three of the assessments the differences were significant at less than .001 level. So that was on the Minnesota expressive language subtest. The Minnesota comprehension and conceptual language subtest, and then also on the Mac Arthur expressive vocabulary measure. We did see differences in all three of those with children who have mild to moderate loss, achieving better scores than children who had mode rately, severe or more significant hearing losses. So even though they are scoring better, how are they doing relative to how they should be doing?  And I will actually backup here to this bar graph.  So in any group of children, any group of children who we assume are developing typically, there will always be a personal of children who will not fall within the average range. And the kind of cut off that we are using for average range here in this graph is children who have scored at least at the tenth percentile or better are being considered to be within the average range. So in any group of children you are going to expect that about ten percent are not going to hit the ten percentile. So conversely, you would hope that 90 percent would be within the average range.  So how does this group of children who have hearing loss compare to that benchmark? Do we have 90 percent of children who are achieving language scores within the average range? And unfortunately, the answer to that is no. We are getting close to that with the Minnesota expressive language subtest and we will talk a little bit about what that subtest is assessing in a moment. But we are pretty far off that benchmark even with child to mild to moderate loss when we are looking at more conceptual language and also when we are looking at diversity of vocabulary. We have more like 65 to 70 percent within the average range, which you know, flipping it around to the positive, that is good.  Sixty-five to 70 percent. But we still have a good, you know, 25, 30 percent of the population even with, quote, just, mild to moderate hearing loss, who are not achieving language scores at the level that they should be for their age. So let's talk a little bit about what the different subtest covers. What are the language skills when most of the children are at age level and when they are still is not at age level? This is informative both in terms of what areas do we want to make sure to assess with this population of children who are hearted of hearing? And what areas do we want to make sure we focus on within intervention? On the general expressive subtest of the Minnesota, almost 90 percent of children were in the average range. And that is what you would expect from any large group of children. And these are language items that tend to be a bit more concrete, more surface structure language items. A few of the examples that are in this particular subtest are things like says or signs ten words. Use the word you in a sentence. Tells the action happening in a picture. Ask questions beginning with what or where. So for the most part, again, fairly concrete, more superficial aspects of language. And in these areas of language, the children in general are doing quite well in progressing as would be expected for their chronological age. The areas where a fairly high percentage of the children were not in the average range were both on the Mac Arthur vocabulary score and then on the conceptual or cognitively linguistic language items on the Minnesota. So the expressive vocabulary, are that is pretty straightforward. They did not demonstrate the diversity of vocabulary that would be typical for a child their age. The cognitive linguistic items on the Minnesota are things like understanding the meaning of the word same and different. Answering questions that are what do you do with a, what do you do with a fork? What do you do with a telephone? That was difficult for many of the children. Things like understanding what full and empty mean. Talking about the future, things that are going to happen. So you can see from these examples that these are not superficial aspects of language. These are deeper structure -- deeper structure parts of language. These are more conceptual. These are more abstract. And these are the areas where children who-all children who are deaf or hearing, are tending to have more difficulty. And even those that have a mild to moderate are still struggling with these sort of language items. Also 'move on and talk now children as they get older. The question here is, do they catch up as they get older? Do they fall further behind? Are there different aspects of language that become problematic as the children get older? Do those who have mild to moderate loss still score higher than children who have more significant loss or do things start to even out? We will now turn to children who are either in preschool or very early elementary, typically kindergarten, first grade.  These are children between four years of age and seven years of age. This is a different data set.  This is specifically children in the state of Colorado. Not part of the more general NECAP study. We assessed 133 children. And I just want to say regarding the sample, it is a little different than maybe some of the studies that have been done with children who are deaf and hard of hearing. In that it is not specific to children --th no as though we went into say a School for the Deaf or a school that had specific self-contained classrooms for deaf and hard of hearing children. This was aid much broader statewide gathering of data. These are all children who located because they had been in our birth to three program and now between four and seven years of age. These children come from a very wide variety of programs. Everything from the state School for the Deaf to their local preschool up the street. So they are getting a variety of different services and variety of different educational programs. So given that, we would probably expect in some senses that these children might be doing a bit better than children who are only assessed -- who are within a self-contained program of some sort. Because many of these children are children who educators and families felt were at a level in terms of language that they could be successful in a classroom that did not necessarily have a lot of supports for children who are deaf or hard of hearing. In this particular study with assessed the children once a year. Right around the time of their birthday. And each child was assessed anywhere from one to four times, depending on at what point they entered this particular project. So all together, there were 320 assessments that were completed they we will be looking at today. So the characteristics of this group, other than their age, is very similar to the characteristics of the birth to three group we were just looking at. They are between four and seven. Tested right around the time of their pirtsdz day. They all have bilateral hearing loss. And they were divided into the two same groups with the same cut off, with tone average of 55 or better, being in the mild to moderate group. Pure tone average is a 56 or higher. Being in the moderate severe to profound group. So we had 50 in the mild to moderate group. And we had 83 children in the moderate-severe group. Just like the birth to three group we were looking at, none of these children had additional disabilities that were thought to interfere with their speech or language development. The primary language of their home was English. But different than the previous study that was based on NECAP data and was multistate. These are all children who live in Colorado. As far as communication approach, again, because this was very broad and not focused specifically on children in self-contained classes specifically for children who were deaf or hard of hearing, a higher percentage used spoken language. About half of those did use some sign very occasionally.  And then a smaller percentage, 12 percent of the group were in families that were trying to sign as much as they could along with spoken language. In this particular sample, there were no children who were using sign language only with no spoken language. I will do a short pause here and I will ask our moderator, Kate, are there any questions that I should address before we move on ? 

>>Kate: There have not been any in the chat at this point. 

>>Sedey: Okay. Well, then I will just keep moving forward: And we will have time for questions at the end so if you do think of something and you want to pop it into the chat, we will have a bit of time at the end to answer questions or hear any thoughts that you might have about what you saw here today. So looking at how well this group of children fell into EHDI guidelines, you will see that the percentage who are meeting EHDI guidelines and who identified early is closer to 50 percent as opposed to the two-thirds. This is really a timing issue because these children are older, it means they were born earlier and also the study was done prior to the NECAP study so we are going back in time a little bit to a point where newborn hearing screening was not as widespread and well entrenched as it is today. We are now look at again half of the kids meeting EHDI guidelines and being identified early and in intervention early. So the assessments we will look at with these preschool and early elementary children, we will look at expressive vocabulary and that will be based on the expressive one word picture vocabulary test which for anyone not familiar with it, it is basically a booklet of pictures. You flip through the pictures and you ask the child to name the pictures. Language comprehension is going to be looked at through the TACL, the test of auditory comprehension of language. We use the third version of this particular test. This is also based on a picture booklet but rather than the child naming pictures, the examiner either says single words or sentences and the child points to one of three pictures that matches what the examiner has said. We also looked at articulation, speech production, using the gold ma'am frisk test. This is a test booklet. Simple pictures. The child names the pictures but rather than scoring them on vocabulary, on whether they got the name correct or not, you are looking at their pronunciation or their articulation of those specific words. And then we also looked at expresses I've language through an instrument that we designed here, written primarily by Diane Goldb;rris. The team in Colorado and it is a pragmatic check, what we call the pragmatic checklist. If you aren't familiar with it, I am hoping I will have a quick moment to put it up on the screen to take a look at it if you feel it would be useful for you. I would be happy to tend it to you. It is not copyrighted or published or anything along those lines. But it is a checklist of different pragmatic language skills that a child may or may not be using. We found this to be a really powerful instrument which you will see in a moment why with this preschool early elementary age, specifically with children who are deaf or hard of hearing. Let's look at the demographics with this particular group. And again these are some areas where we did not see any differences. Which again is great because as I just mentioned, these are children who were born even earlier because they are older and because the study was done earlier, compared to the last group we looked at. But we are still seeing the phenomenon that those children who have mild and moderate losses are being identified and are in intervention at essentially the same time as children were more significant losses. And again, this is a big change from what let's say 20 years ago when the children with mild to moderate losses very, very often were identified quite late. Often not until somewhere between five and eight years of age.  The mother's education was no different than those with significant loss. These factors that could influence a child's language development would not be something that would come into play in looking at a group comparison because the two groups are comparable on these different factors. And here you can see, you know, again, the differences are very small. But I think it is kind of interesting that the mild to moderate group was actually identified slightly earlier than the moderate, severe to profound. We are talking about a month. So not a big deal. But they got into intervention just slightly later.  So that would be kind of an interesting thing to explore as to whether maybe the immediacy is not -- people don't feel the immediacy in the same way for a child whose loss is mild to moderate and they let time lapse between identification and intervention compared to children with more significant losses that there might be a more urgent sense that she should be enrolled in intervention right away. So that might be something to, you know, systematically take a look at and identify a child. You want to get them into intervention as soon as possible. Another area, this particular group of children actually all participated in a nonverbal IQ test, specifically the Leiter, nonverbal IQ test. This is an area we saw no degree of difference. On the average, the performance IQ for the mild to moderate group was 104. Right about where it should be which is 100.  And the average for the moderately severe to profound group was 103. So basically the same.  So again, we can't explain any differences between the two hearing loss groups because of nonverbal cognitive abilities because the two groups are basically the same in that regard. And this also, you know, is a nice confirmation that these really are children who don't have additional disabilities that would impact speech or language because their performance IQ is right exactly where it should be. Right around 100. Let's look at some comparisons and we will start with language comprehension. So the TACL has three subtests. The first set of bars is the vocabulary subtest where the examiner says words and the child points to one of three pictures that matches the words. Second looks at grammar and then the third looks at elaborated sentences which are longer complex sentences. We can see that similar to birth to three, that the children with mild and moderate loss continue to have an edge.  Now, on the vertical axis, we no longer have language quotients because all of these administered tests we will be talking about, they all have standards scores. We are using standard scores. Interestingly, the average standard score for a group of typically developing kids is ten.  On the TACL the children with moderate -- mild or moderate hearing loss, their standard score is closer to 11 as opposed to ten. Even though it doesn't sound impressive because it is just a point. Because it is a standard score, that is actually a lot. Three standard score point on this test are considered one standard deviation.  So these kids are basically on average scoring a third of a standard deviation ahead of what would be typical for children their age. So on this particular test, they are doing very, very well.  The children with moderate, severe to profound loss are a little below on the grammar and elaborated sentences but are right on on track with vocabulary comprehension on this particular test. Expressive vocabulary, again, we looked at that with the expressive one word, picture vocabulary test and that is the two bars on the left. Again, we are seeing the same pattern we saw in birth to three that the group of children with mild to moderate loss are scoring higher than the group of children with moderately, severe to profound loss. And on this test, the standard score of 1 is hundred is considered to be like just exactly average for your age. Exactly what you should be doing for your age. So very exciting to see that the children with mild to moderate loss are basically hitting that 100. Children with more significant losses are not quite at that point yet but are approaching and getting close. The second set of bars on the right, that is the golden test.  That is it speech production, a standard score of 100 would be exactly where the child should be for their age and we do see children with mild to moderate loss falling significantly short of that.  Their standard score is a little over 80 as opposed to hitting 100. But again, we see a big advantage compared to the moderate to severe to profound group. As a little aside because I found this somewhat interesting.  In order to break our groups into those with more mild degrees of hearing loss, those with more significant degrees of hearing locks we initially started out looking at each individual degree of hearing loss and how the children were doing, to see if -- do we see a stair step as we Brent mild to moderate to severe. We see it gradually decreasing as you get more significant loss. Or did we see kind of a chunking where it was like, mild to moderate kind of looks similar and moderately severe to profound kind of looks similar? And it was the latter. They kind of chunked into two groups. Which is why we combined them for this analysis. But interestingly for articulation, the moderately severe group looked way more like the mild to moderate group. So in an effort not to make it too confusing and start redividing the groups for different measures, I left the grouping the same but if we had taken the children who had mode rately severe loss and added them to the mild to moderate group we would have seen even a more dramatic difference in the articulation scores of the two groups. So when it comes to language, children who have moderately severe loss look more like children to mild to moderate loss. Those are moderate loss are like those with moderate to mild loss. I think that is interesting from the standpoint of making sure that these kids with moderately severe loss kind of like the middle child, don't get lost for us in the system. They may in a sense fool people with their good speech production. So they will produce speech and be -- have speech intelligibility and articulation skills that are very similar to children who have mild to moderate hearing loss. Yet, their language is very much like a child with more significant loss. So this is a group to really watch out for, these kids kind of right in the middle. The middle child.  Not to get fooled by their good speech production and taking a good solid look at their language skills and to realize that despite the very good articulation skills they have, they do need a lot of support when it comes to learning language with vocabulary and grammar. The last instrument we looked at with these preschool and early elementary student was the pragmatics checklist.  It does not have norms per se but we do have benchmarks because we have used this with a group of over 100 children who are typically developing in children who are hearing. So a child by the time they are four, which all the kids in this sample were at least four, most of them older.  Five, six or even seven. By the time a hearing child is four, they were able to essentially do every item on the pragmatics checklist and able to do it with sentences of at least four words in length. If you are not familiar with the checklist, there is a variety of different pragmatic skills on it. Everything from explains how to play a game to changes their language, depending on who they are talking to like an adult versus a child. So uses greetings, uses uses politeness. Requests things politely. Able to make clarificationes. So lots and lots of different skills in language and a four year old child who is hearing typically can do all of skills. Maybe not one or two. By the time they are five, they can really do all the skills and do them at the highest level. For each of the skills you have the opportunity to checkoff, no this is is not a skill the child is using yet. They are doing the skill but doing it nonverbally, like through gesturing and facial expression. Or they are doing it with very short phrases or just single words. So one to three word utterances.  Or the highest level would be doing these skills with sentences of at least four words. A four year old child that is hearing will get 100 percent of the points. Because they will be doing all the skills and they will be doing them with sentences with four words or more. So what we are seeing here with the kids that are deaf or hard of hearing is the group who have mild to moderate loss, they are getting a little over 80 percent of the points that they could. They are not getting 100 percent. Again, they are getting a higher percentage compared to the children with moderate, severe to profound loss.  But this is an area where in preschool and early elementary, there is still gaps in the language ability. Again comparing the two groups, hearing loss groups, once again we did T-test comparing mild to moderate to moderately severe to profound on each of individual language measures. We did see differences by degree of hearing loss on all four of the preschool elementary measures so we saw differences in expressive vocabulary, language comprehension, speech articulation and pragmatic language. Then how do the children who mild to moderate loss do relative to how they should have been doing based on their age? We did see that the children did very well on the expressive vocabulary test and in terms of language comprehension. But this is not to say that we need to be complacent in these areas because I will say having seen many, many children take both of these tests, that when you compare how they do on these test, it often seems a bit high relative to what their language kind of really is in a day-to-day or spontaneous language context. So any test that you would administer to a child, preschool and above, is not going to be like the Mac Arthur where you have the opportunity to look at many, many words and indicate very specifically which words the child is able to produce. This is a sampling of vocabulary so you are not giving a test for five hours. And if it happens, that sample of vocabulary happens to be some of the words that the child knows and they are common words on the test. The child will do fairly well and it is not necessarily an indication of the depth and the breadth of their vocabulary.  Although the children, you know, and it is exciting, we are meeting age at a test. It doesn't necessarily mean that their expressive vocabulary is exactly the same as a child their age who is developing language more typically. So looking at the expressive vocably not just terms of a test but the variety a child is using is super important, both with child mild to moderate loss and then also of course for children with more significant losses who even on this test were not at age of expectations. The areas where we did definitely see deviation from hitting the average of children who are developing language typically were articulation and the pragmatic area of language. The mean standard score on the articulation test for our group of kids with mild and moderate hearing loss was 84. The mean for hearing children would be 100. So that is a pretty big difference in terms of their ability to produce different speech sounds and in particular the Goldman Fristo looks at consonant production.  Being able to produce different consonants.Th an interesting -- it is an interesting piece that can be useful, say at transition or in the early school years when you are looking at IEPs or service of speech pathology services for these kids. What we often hear is that being in an IEP meeting and look at an articulation test and say, well, you know, I don't think we should qualify this child for speech therapy services because the sounds that they aren't producing are later developing sounds. So they might be having trouble with the R, with the S, the with L, with the consonant blends and that is often true. They are having more difficulty with later developing sounds. But the key here is twofold. And this is why it is still important for them to have speech therapy services. Number one, most children who are hearing might have trouble with one of those sounds. So they might have a later developing sound like an R that hasn't come in yet but they don't have trouble with all of them. They don't have trouble with R and S and the consonant blends and L. So even though those are later developing sound it is not typical to have difficulty articulating all of them. So looking at the  standard score on this test, is I think super important as opposed to looking at the individual sounds that the child can't do. Now, the speech therapist is going to look at the individual sounds when they write their goals and plan their intervention but in terms of determine determining services or not, the standard score is crucial to get a feeling for whether the number of articulation errors the child has are outside the typical range. The other piece of it is that a child who is hearing often will fix those later developing sounds just on their own. Because they hear the sound. They hear it accurately and they will eventually start to meet that model. But the reason that many children who have mild or moderate loss are not articulating those sounds is they don't hear them accurately. Or even with their amplification, the sound doesn't sound the way that it would sound to somebody who doesn't have a hearing loss. And so they often do need extra assistance in order to learn to produce those sounds. They aren't things that will just be fixed over time through listening the way they would with a child who is hearing. That is the articulation piece. The second piece is really looking at expressive language from pragmatic standpoint. The child might have a good vocabulary. They may have gained good gram Arkansas skills but are they using that language in a variety of different contexts, for a variety of different functions? And this is where the pragmatics checklist can be can be really helpful and a great tool. This is spg in you are going to the IEP -- if you are going to the IEP table and the child lingsz 'scoring has a standard score of 100. That is typical. They are in the average range, having an instrument like the pragmatics checklist and being able to say, we know a four year old could do all of these skills. Using four plus word sentences. Let's see how this child who is deaf or hard of hearing is doing. What skills are they lacking? And what skills are they demonstrating but not with more complete sentences. In this group of children, and this is specifically those with the mild or moderate loss, they were getting about 86 percent of the points they do have. Where the hearing child is getting almost 100. This is definitely an area to be looking at and to be focusing on. To conclude, we did find that the children with mild to mode rate hearing level across the whole range were achieving higher language scores than children who had moderate, severe or profound loss. However, keep in mind that typically they were not scoring at the level that they should have been for their crop logic age. So about a third of the children with mild to moderate loss were exhibiting de-- crop logic aage. As opposed to being a test of a sample of vocabulary. And they also were exhibiting delays in conceptual language skills.  And that was in the birth to three group we saw that. Then in the four to seven groups, the same thing, they were achieving higher scores in children that had moderately to severe to profound losses. However, they were often exhibiting delays both in articulation, speech production and in the pragmatic language skills. In a concludes.  One quick point. Just general take home here.  When you are thinking about assessing and planning intervention for children who are hard of hearing, the areas that I would RAM putting most focus on is diversity and depth of prexes I've vocabulary.  Expanding that vocabulary as much as possible. And one thing to really think about is focusing on having more than one word to express a difficulten -- given concept. What we will see with children who have language delays. Once they are able to express a concept, let's move onto another concept. What they lack is synonym which is is problematic when it comes time for reading and writing. So and then also specificity of vocabulary. Often for children with language delays, if they can say dog, good, let's stop there. But think about what a hearing child can very quickly do. They don't just say dog. They are saying poodle, Dalmation. They are saying German Shepherd and we wanted the children who are hard of hearing to also have this kind of diversity to their vocabulary. Because again, not only is it important for face-to-face communication but critical when it comes time for reading and writing, to be a good reader and a good writer. The other thing to focus on is using abstract language t cognitive skills, those that I gave example of on the Minnesota. As the child is getting close to preschool age, in preschool and above, focusing on the pragmatic language skills.  Let me see if I can care the pragmatic checklist.  Hopefully people can see it on the screen. My moderator can tell me if that is not the case. I will make it smaller here so we request see more of it. It is a checklist. Very easy to administer either by a teacher, a speech pathologist. It could be given to a parent if the parent has never seen it before, it is good to kind. Walk them through it and give them assistance on it. You can see it has a whole variety of pragmatic skills. Starts with the easier pragmatic items, makes choices, requests help, ebz presses a need. These are also some of the earlier items. Give directions to play a game. Give directions to make something. Then we start getting into the more difficult items, things like offers an opinion with support.  Provides excuses or reasons. Explains feelings.  Not just I am happy but I am happy because I just got a new bicycle. Then we get into interactional kind of language items, things like preparing a message that something didn't understand. Ending conversations appropriately. Asking for clarification when they don't understand something. And down their -- down here we have things to retell a story. Make sure the story has a beginning and an end. Role-play using props.  Asking questions because you are curious about something. So lots of great language items and I think this is really nice the share with families.  Even in the birth to three, even though we are not really expecting to see a lot of these until closer to three and a half to four years of age, they do start -- typical three year old can do half of the items on here. It is really nice to show to families in the birth to three period to give them an idea what is coming up and all the different ways that we use language beyond vocabulary and grammar. That concludes. Do we have any questions to answer in the chat, Kate? 

>>Kate: Sorry, I couldn't find my unmute button.  Kathleen asked have you incorporated either the VCSL, visual communication sign language assessment or the LDS in assessing children birth to five? What are your thoughts of these two assessments in comparisons to the ones discussed today? 

>>Sedey: The VCSL was not in existence at the time we started this particular study. That wasn't a choice that we could make. Also we do as a mention have a current study called ODDACE. We recommend the VCSL and it is an excellent instrument for children learning ASL. But one of the issues with that is more of a logistic issue in that you have to have the a trained examiner, a certified trained examiner administer it. It does limit. It is in a sense utility and availability for people to administer. But if you do have access to a trained and certified administrator, I think it is an excellent measure of ASL and a nice addition. The four to seven group we have here, none of the children were -- some of the children were using sign language but it was more sign supported spoken language. Or PSE. It was not ASL. The instrument would have really not been appropriate for this group. But in a group of children or if you have individual kids using ASL, I think it is excellent T LDS, the language development survey, very certainly widely used.  It is a great clinical instrument. Really great for helping parents to see the stages of language development, creating goals. The one issue with that test and why we did not use it, because that test of course did exist. It has been around for a very long time. It is a criterion reference test. For of a -- more of a chest lick that has age benchmarks. It is not norm referenced where you can lookup a standard score or an exact age equivalent. You can say, well, they got half the items right or three quarters of items that are in this age range but it doesn't give percentile range. It doesn't compare. They were normed tests. That was one of our criteria for selecting a test. 

>>Kate: Lisa asked a follow-up question. What is the age range for the pragmatic checklist? 

>>Sedey: Three to seven. Three years to seven years. A three year old, like I said, you would expect they might get like in our group of hearing kids, the three year olds got 20 of the -- 20 out of 45 items. A little less than half. Kids are starting to be able to do the items at age three and then by really honestly by age five, in a group of hearing kids, they topped out. They knew everything. But in children who are deaf or hard of hearing, because this tends to be an area of language where kids show gaps,th useful all the way up to age seven and possibly beyond if it is a child that has more significant language delays. 

>>Kate: Sara asked any control or data regarding am live indication, consistent, not consistent, daily, et cetera? 

>> Sedey: No, not for this particular study, we did not have this position. 

>>Kate: And then finally, Christine just wanted to say that you mentioned the ODDACE but didn't talk much about it. Do you want to wrap up by sharing a little bit more about the ODDACE? 

>>Sedey: Sure, I would love to you. Thank you.  So ODDACE stands for outcomes and developmental data assistance center for EHDI programs. Just in a quick nutshell, it is similar to a prior project we had called NECAP. What we are doing is working across programs in the United States who would  like to contribute to a national database of out comments and get support around doing a couple of instruments that will be consistent across the United States that we will all be using. It gives programs the ability not only to be assessing their individual children who we then score assessments for them. We send back a nice report of how the child is doing and so it allows programs to monitor their individual kids with a standard battery. But also we created database for the program whereon an annual basis we can report back to the program accountability data to say, hey, as a group, here is how the children are doing. Here is the progress they are making.  Here is the language outcomes and here is how they are doing compared to the other states that are participating. Not only does a program get an accountability of their children but relative or compared to other programs across the United States using the same instruments. The two instruments that we are using are the development assessment for young children and also the Mac Arthur communicative development inventory. And we have opportunities for optional assessments as well. Things like the pragmatic checklist, the sky high LDS that the programs are using also. If anybody has any interest in that, either participating an individual interventionist or your whole program participating, please get in touch because we would love to have you join us. 

>>Kate: One last question snuck in. Is there a checklist that you recommend we use to monitor the breadth and depth of language? 

>>Sedey: Well, in the birth to three period, I love the Mac Arthur. And it is primarily vocabulary that you are looking at but I do love that assessment. I will be honest that as children get older it become tougher.  Standardized assessments are sampling and general items and I feel like children who are deaf or hard of hearing will score somewhat unrealistically high on those tests. If you have the bandwidth to do it, I think nothing beats a spontaneous language sample. Recording the child, it is a lot of work. But you can even do sort of an abbreviated version where you are just jotting down some of the sentences and phrases that you are hearing a child say. Really just looking at those to see what kind of diversity vocabulary?  Are they using simple words or kind of big girl, big boy words in there too? Using all the grammatical functions? Are they missing things?  Are their sentences short and simple? Are they using complexes sentences with dependent clauses?  Nothing beats that to me and that is really where you will -- that is the whole ball game is spontaneous language in the end. It is not naming pictures on a picture plate. So it is not exactly a checklist. But I would recommend that. The castles from sunshine cottage is a great -- if you are looking for more of a checklist situation, I think it is really good. So I would take a look at the castles that sunshine cottage has developed and published. 

>>Kate: Wonderful. Thank you so much, Allison. Great resources. 

>>Sedey: Kate, I don't flow if you want to give a couple of minute break before Christine starts.  We are at 11:00 right now. 

>>Kate: Maybe take like one minute. Christine, you start when you are ready to go. We will put Christy in charge now to tell us when 

>>Yoshinaga-Itano: I am happy for people to take a stand up break before I start. I have it is 11:03. I will start at 11:05. To give people a chance to stand up. 

>>Kate: Sound good. I know, I just raised my standing desk and I am ready for this next hour. 

>>Sedey: I actually looked at my watch and not the computer. You are right, we are going good on time. 

>>Yoshinaga-Itano: Allison, I just wanted to share with you that the pragmatics checklist and all of the data by item is on the Marion down center research.net website. 

>>Sedey: Oh, good. Maybe just mention that, right -- 

>>Kate: I put it in the chat so people who were on do know that. 

>>Yoshinaga-Itano: Oh, good. Okay. I will go ahead and start. It is 11:05 so hopefully people are back from a break. The topic I will speak on today is what has happened to reading proficiency of children who are deaf and hard of hearing since we have begun to implement universal newborn hearing screening?  For disclosure the funding for the research studies included in this presentation were from the disability research and dissemination center through its cooperative agreement from the Centers for Disease Control, national center for birth defects and developmental disabilities. And I will briefly mention something about conversational turn taking and I just wanted to state that I am an unpaid member of the scientific advisor board of the LENA Foundation. Prior to universal newborn hearing screening, reading proficiency assessments, I think many of you actually probably participated in this if you also served not just the birth through five or six population but also the school age population.  They were collected on large samples of children who were deaf and hard of hearing, actually I think it was lodger than 1974 to 2003. But the research -- the beginning research that I am going to show you to show you what we know about children prior to implementation of universal newborn hearing screening is in the years 1974 to 2003. And this data -- massive data collection across the United States, were from children assessed through the Stanford achievement test and collected by Gallaudet University. It included third and fourth grade all the way to 12th. The reading proficiency of the third graders who were eight year olds and the beginning of the test taking were at an average middle first grade equivalency. From the time period between 1974 and 20003. By the time they were ready the leave the regular schooling at 12th grade or 18 years of age, they had a mean reading proficiency score between the third and fourth grade. But the mean never actually reached fourth grade. Indicating that the average reading score was about eight to nine years delayed for those 18 year old children.  So children on average were functioning about 50 percent of their chronological age when they left school. Now, the norming population for the Stanford achievement tests on deaf and hard of hearing was very large. You can see that the smallest sample was at tenth grade in 2003 with 3,569 children. But the seventh grade, they had in 1983, 8,311 children. And 1974 they had 68 -- 6,873. This is a huge sample across the United States. Now, there have been some other research data, the California Department of Education 2007 reported that eight percent of children who were dough and 15 percent who were hard of hearing scored proficient or advanced. And Cawthorn in 2008 reported reading proficiency from state schools for the deaf in 21. One of the example reported on was in Louisiana that reported that 15.6 presents of students scored at the proficient/advanced range. They weren't all broken out by degree of hearing loss but it looks pretty consistent from this 21 states who participated. So this is a study that was actually fairly recently at least within the last ten years published. It is by Qi and Mitchell in 2012. And this gives you longitudinally the mean grade equivalent from 1974 to 2003 from the third, fourth graders to the 12th graders. And you can see that there is some difference by test year.  The range of the means is pretty narrow. And even if you look at the 18 year olds between 1974 and 2003, this is where you can see that the best year was 1996 and that was still below the fourth grade equivalency. That is just to give you some background on reading proficiency across the age ranges prior to universal newborn hearing screening. This data comes from the state of Colorado. And it represents the years of screening from -- from 1992 to 2006. The state of Colorado passed legislation in 1998. What you see here if you look at 1992 and 1997, we were screening less than 20 percent of birthing population. Then it jumped up toe about 45 percent in 1998. And then 50 percent in 1999. But after we passed legislation, you can see this there was a major jump so that by 2000, we with were over 80 percent and by 201 we were over 90 percent more in the 97 to 98 percent range of screening the birthing population. Now, when you look at the birthing population, you have to think to yourself, okay, it will be eight years from their birth year. So if we take the birth cohort of 2000, right, they are not going to be able to take the reading proficiency test until 2008. The birth cohort in 1992 would have just begun to take the reading proficiency test in the state of Colorado in the year 2000. Now, I will be reporting on a specific school district. It is a very, very large school district in the state of Colorado. And it has quite a bit of diversity.  So 71 percent of this school district and also of the sample that we have identify as racial, ethnic minority. 37 percent of the pop -- 38 percent of population do not speak English in the home and 71 percent qualify for free and reuse thed lunch.  So -- reduced lunch. Each school district has varying diversity and so for example, in the school district in which I live, about 20 percent of the children qualify for free and reduced lunch. What you can see here is that this is a district where they have a lot of risk factors for their population. Now, when we look at universal newborn hearing screening implementation in Colorado, the average age of diagnosis for the period that we will cover is three months of age. That was true almost from the beginning of our universal newborn hearing screening period. When we look at the CDC data during the time period covered, 80 percent of the diagnosis were made prior to three months of age.  Many by one and two months of age. And 80 percent met the one-three-six. I will say that varies by year in the state of Colorado. But only to give you some background that many of the children from the time that we began universal newborn hearing screening were identified early and had early intervention services. One of the limitations of the stories is, we collected statewide data in a paper data management system and did not track the children individually. We have a number of children who were identified but we were not able to match their screening with their reading proficiency scores. We only know that the population, what percentage of the population was screened. So what we know from the general results of this study is that each birth year, so that is with each additional class born, having been born during a time of universal newborn hearing screening implementation, that reading proficiency increased. We also know that the exemptions decreased and for example, in the year 2000 for test administration, we only had 17 children in the district who were deemed eligible to take the reading proficiency test this is a statewide test at every grade level third through tenth grade.  And in the year 2000, if the district felt that the language levels were not sufficient, the children were engz emented from taking this test.  However, by 2013 and 2014, you will see that the numbers increased where we were having between 165 and 171 children taking the proficiency exam in this particular district. One of the exciting findings it is not only the birth year where we saw increased reading proficiency but across all subgroups. We also saw that the children's reading proficiency increase Wednesday each grade level in school -- increase Wednesday each grade level in school. They were closing the proficiency gap for every year they were in school. This differs dramatically from the pre universal newborn hearing screening data where the gains in reading proficiency were so small that actually what was happening with the vast proportion of the children is that their discrepancy in reading between their grade or chronological age was actually increasing, not  decreasing, as they progressed from one grade to the next. So in this graph, you see the test years that we looked at because the first bar in 200 to 2001 to 2013 to 2014. What you should look at in this is not only the change in the number of children who were taking the test. So in 2000 it was 17 and then the next year, 27, the year after that, 44.  2004, 2005, 74 children. By the time we get to 2011, 2012, 169 children. The next year, 176.  The year after that 173. So now when you look at the pink bars, look at the change over time. The pink bar represent the percentage of children who were unsatisfactory. And you can see that that was very high the first year of the test. It was just short of 08 percent. And then by the time we are down to me 2013, 2014, it is just a little over 30 to 35 percent. The yellow bars represent the children who are partially proficient. Now, there was a change from the very beginning of testing but it leveled out and you can see that the partially proficient children stayed relatively stable over quite a few of the testing years. If you look at the green bars, those are the children who are proficient advanced and you see a dramatic change from 2000 to 2013 to 2014.  Where in the beginning it was a very small percentage. I think it was about 17 percent in the year 2000 and now you look to see that by 2013 to 2014, it is close to 40 percent of the children are in the proficient, advanced range. Now remember, that this is the total population. It includes children from third grade all the way through tenth grade. And again, remember that the fourth graders were better than the fifth graders and all the way up to the tenth. To describe the difference, in 2013 to 2014, if we add together the partially proficient to proficient and advanced, 68.5 percent were in that category. So nearly 70 percent. And that is a change from only 18.8 percent in the years 2000, 2001. Now, the decrease in unsatisfactory is dramatic. It went from 381.3 percent to 31.5 percent. The change in the partially proficient category is the smallest from the 12.5 percent to 31.5 percent. And the change from proficient advanced increased from 6.3 percent to 37 percent. Now, that is the total population. What I am going to talk about now is how that breaks down by other variables and including the variable of the mild/moderate hearing loss. For those children who were not eligible for free and reduced lunch, the change was the most dramatic. Unsatisfactory reduced to 75 percent from 75 percent to 4.5 percent. So there were hardly any children who were in the unsatisfactory range and remember that this covers from third through tenth grade. But again, these children were never eligible for free and reduced lunch. Which means that they did not have socioeconomic challenges as measured by family income. The partially proficient group remained about the same. But the proficient advanced increase from zero percent to 70.5 percent. So what is most remarkable about that is again, it covers from third through tenth grade. And since 70.5 percent are already proficient advanced, it means that the children in third grade, there is a fair number of them who are already proficient advanced. And that they are gaining from that proficiency every year, they are keeping up with their regular children. This includes children who are mild moderate as well as children who are moderate severe and profound. There is a discrepancy for children who are eligible for free and reduced lunch. Remember I said for all subgroups the increases in reading proficiency by both birth year and grade were significant.  However, the gains were significantly less for those children who qualify for free and reduced lunch. Unsatisfactory decreased from 83.3 percent to 41.3 percent. Partially proficient increased from 8.3 to 33.9 percent. You can see that they are moving from the unsatisfactory to the partially proficient and the partially proficient to the proficient advanced. The proficient advanced increased from 8.3 percent to 24.8 percent. You see the difference between the 70.5 percent who were in the proficient advanced when they were not eligible for free and reduced  lunch. Now, we also had a fairly large population in the school district from nonEnglish speaking homes.  And we had a surprising result. The children who were nonEnglish speaking made significant reading proficiency gains by birth year and by grade level. But remember that we are using proficiency categories. And when we use proficiency categories, we did not find a significant difference between the English and the nonEnglish speaking group. But remember that we are also accounting for issues like free and reduced lunch, the language spoken in the home, and so these are -- and the presence or absence of additional special ed services beyond services for hearing loss. So this just shows you that the remarkable change in the nonEnglish speaking children from -- the children who are nonEnglish speaking in the home.  And you can see that unsatisfactory pink range also dropping dramatically. You can see that the partially proficient in the yellow is increasing.  And the proficiency advanced in the green is also advancing. We also looked at children with hearing loss only and those were defined by the special education services beyond hearing loss versus those who were receiving special ed services in other disabilities. Now, the one thing that you need to know about this category is that we only took children who were staffed from IEPs with hearing loss as the primary disability. So children with hearing loss plus autism or severe intellectual disabilities would not be included. It was hearing loss primary in terms of their IEP status.  Now, again, this subgroup, all of children made significant gains by birth year and grade. We did not find significant differences again in their performance category between children with hearing loss only and those with primary -- and those who had additional special education services because of an additional disability. Now, that is likely because the additional disability would maybe -- articulations problems or they were receiving for learning disabilities. But again, this did not include children with more significant additional disabilities like autism or severe intellectual disability. We looked at laterality of hearing loss. And here is where I am getting into the effect for children with mild/moderate hearing loss. There was no significant difference for children with bilateral mild/moderate hearing loss and children with unilateral hearing loss. These are children in the state of Colorado. I know many of you live in states where children with unilateral hearing loss are automatically qualified for early intervention services in birth through three. That is not the case in the state of Colorado for this birth cohort. In order to get early intervention services for children with unilateral hearing loss, the children had to show significant delays. Now, what is interesting is that Allison Sedey has done studies looking at children in the NECAP program which is across states that are not in the state of Colorado. And the birth through three period there were some very similar outcomes for the bilateral, mild moderate and the unilateral hearing loss. Now, many of those other states were offering early intervention services. And those are significantly less in intensity than the services that are offered for children with bilateral, mild, moderate hearing loss. So here is the graph for the children with the mild, moderate hearing loss and you can see that the unsatisfactory in this graph are in the orange. The partially proficient are in the yellow and the proficient are in the blue. And you can see the difference between the 2000 results and really 2001, 2002 and the children in 2013 where there were many more children who are taking the test now and you can see an increase in both the proficient advanced group and the partially proficient group and the decrease in the unsatisfactory. Now, this is the comparison with the children with unilateral hearing loss. It is quite similar to the children with mild moderate hearing loss and that is why there were no significant differences. When we compare that -- I guess I did not -- I will talk now about comparing those children with children with bilateral, moderate, severe, profound loss.  Both categories, the bilateral hearing loss and the unilateral hearing loss category had significantly better reading proficiency than those with bilateral, moderate to severe profound loss. Again all groups made significant gains by birth year and by grade. Here is the graph for the bilateral severe profound. The primary gain for those with significant hearing loss is in the partially proficient area. And also the decrease in the unsatisfactory category in the orange. Again, there were no significant differences between the unilateral hearing loss and the bilateral hearing loss category. Children well unilateral hearing loss, those again this is a very high risk population should be considered for the early intervention services as those with bilateral, mild moderate hearing loss so we can see that when we look at the population from third grade through tenth grade -- I am taking a break because there is -- noise in the background. So again, because of the similarity for children with bilateral, mild, moderate hearing loss, I think we should reconsider the services that are being made available children with unilateral hearing loss who look very similar to this bilateral, mild, moderate hearing loss. I will show you the results from the reading proficiency in a different way. In this case, the outcome is with scaled scores rather than for proficiency level. This was done for 3389 children with one call it the statewide testing is CSAP or CTAP.  The test scores available for this children are 4.37 test scores. There were 833 cases of consecutive CSAP scores representing 204 students.  Now, again, the differences we are looking at the scaled scored outcomes shall not the proficiency level. So if you look at this demographic by home language, remember when we were looking at the proficiency levels, we did not find a significant difference. However, when you look at the scaled score difference there was a significance difference with the Spanish children who were in Spanish speaking homes. There were just a very few children in so Mali speaking homes. The great news for the Spanish speaking as well as the English speaking, they improved with every birth  cohort and improved with every grade in school. Now, here is just a different way of showing the free and reduced lunch children. And you can see that -- some of the children qualified every school year for free and reduced lunch. Some of them qualified for only a couple of years. You can see at the bottom what is here is 20 percent, 40 percent, 60 percent, 80 percent, 100 percent of the school year qualifying for free and reduced lunch. There was a significant change as you can see in the scale scores dropping. When children were more qualified for free and reduced lunch or had a higher percentage of their test years. Now, here is the difference between mild, moderate versus severe and profound and children with cochlear implants. And you can see that there is a significant difference but it is not that large actually when they are looking at just the scaled scores. The mild, moderate hearing loss were significantly -- had a significantly higher scaled scores than the children with moderate, severe and profound hearing loss. Here you see the unilateral with bilateralful even when we are looking at scaled scores and not proficiency levels, we see there was not a significant difference between these children. So even when we look at it in different way, we are not seeing significant differences. When we look at presence versus absence of other disabilities besides hearing loss, when we are looking at scaled scores, we are seeing a difference in the range as well as the mean, again, the difference between this analysis and the analysis that I talked about earlier, we were looking at proficiency levels shall not scale scores in the other. This will not be surprising. I didn't say anything about child who were in gifted and talented programs.  But since universal newborn hearing screening, we certainly have an increase of children who qualify for the gifted and talented program. And the reading score for children who spent more time in gifted and talented programs were higher than for those children who were never in gifted/talented programming. This relates to children who were staffed for 504. Again, this -- children were not immediately staffed in third grade for 504. So what you see again at the bottom of this graph is 20 percent of their assessment times. 40 percent.  60 percent. 80 percent. 100 percent of their assessment time. Versus never being in 504. And what you see is that as the percentage of the assessment years increases when the children were in 504, logically speaking, we see a significantly higher reading score for those children. And that makes all kinds of sense because their reading proficiency is related to their special education staffing. This is conversely showing just the opposite, that the higher the percentage of the years in which the children were tested for reading proficiency, where they were qualified for IEP and special education services, these children had reading scores which fell as the participation percentage increased. This is to show you by grades that for each grades, so the first blue bar is the range and the mean of the children in third grade and this is going up through tenth grade and what is exciting about this is is not only is the mean increasing significantly with every test year, meaning that the children are actually increasing the scaled score. So they are closing the gap with each grade level in school. The other thing you should notice is that the range is decreasing. The mean is increasing. The range is decreasing, meaning that we have fewer and fewer children with poorer and poorer reading proficiency scores. Now, this is just to show you that by birth year and therefore by implementation of the newborn hearing screening, we see that the means are increasing and the range -- well, actually the range in the first year is very small because there were so few children who were taking the test. And then you see as more children took the test, there was an increase in the range. Certainly as we implemented newborn hearing screening over time, the reading proficiency scores were definitely improved. Now, remember that this is a state in which meeting one, three, six is really strong.  What we have seen over time is that meaning 1-2-3, that there is universal hearing screening population that are meeting 1-2-3. I think this is really key for the children who are the most -- who have the greatest disadvantage. The racial ethnic diversity is really compounded with the socioeconomic challenges for these particular groups. Lower levels of maternal education.  Children who are in nonEnglish speaking homes.  Being able to officerlier intervention for these families is significant. I will talk about this a little bit going again to the four to seven years group that Allison talked about with respect to the pragmatics. This is the same group of children but I will talk about their expressive vocabulary scores specifically and I am breaking it down a little bit more by degree of hearing loss. And I just want to say that the Colorado children have had early intervention from a deafness early intervention. What is not true across the United States. And for the most part, not all of the NECAP participating states had a specialized early intervention in childhood deafness system but most of them did. The reason for that is that it is a lot easier to collect assessment data in a state when the chill drn are in a deafness specific program. And that is true for the children across the state of Colorado. What we did have -- we had a pretty stable amount of service by intensity of service and the children received one to one and a half hours per week in early intervention. They also had an option for sign language services once per week. They were standardly assessed every six months. So as Allison reported, we did use the expressive one word picture vocabulary test. The difference in this analysis that I am going to show you is that we use meeting EHDI 1-2-3 instead of 1-3-6.  We used an analysis of their -- videotape analysis of parented child interaction. There were a few children in which it was teacher child interaction but we did have individual video tapes that we analyzed and transcribed. We used degree of hearing loss, nonverbal IQ and their language scores when they transitioned from birth through three to part B. Now, on its own, degree of hearing loss accounted for 21.8 percent. And this again was mild, moderate versus moderate, severe to profound.  With mild/moderate, children having better expressive one word picture vocabulary test. The Leiter test across the whole population accounted for 32.5 variance in the expressive one word picture vocabulary test. And what was good is that degree of hearing loss did not impact the Leiter scores. The distribution as Allison talked about of Leiter was very similar. What you can see is that for the uncontrollable variables and these are degree of hearing loss and the Leiter scores which is the cognitive intelligence scores of children, early intervention doesn't change or part B intervention doesn't change either degree of hearing loss or the cognitive scores of the children. And it accounts for over 50 percent of the variance in the expressive one word picture vocabulary test. Here is just to show you from 36 months to 7 years of age, the difference between mild, moderate and also in here are progressive hearing loss. And the reason that progressive hearing loss are in here, these are children who had mild, moderate hearing loss at birth but progressed often times to severe, profound and cochlear implant candidacy between the years of three to seven. They were included because their scores were so similar to the stable mild moderate hearing loss group that that they were indistinguishable and were very different from the children with severe to profound hearing loss at birth who remained stable over that time. So you can see that by seven years of age, the children with mild, moderate, progressive at 84 months of age, as Allison said, they were above age level. Right.  So they were at 92 months instead of 84 months.  It is almost -- that is quite a bit of difference versus the children of severe and profound loss who were about at 72. But you can see that that is a pretty significant difference by degree of hearing loss. And that change increased over time. So from three to seven years of age. Now, with the Leiter, between, uncontrollable.  But what you see is that if you are one standard deviation for the Leiter on this group, your vocabulary scores was right at age level. I mean, sorry, when you were at the mean it was right at age level. When you were one standard deviation above the mean you were almost ten months higher on the express vocabulary and if you were one below the mean you were almost ten months lower.  Almost a year. But not quite. Maternal level of education also uncontrollable.  Accounted for 13.1 percent of the variance in outcome at 84 months of age. But when you controlled for degree of hearing loss and Leiter score, it dropped to 2.8 percent. The Leiter scores impacted most of the drop in maternal level of education to about 4.3 percent, indicating that there is a relationship between mother's level of education and the child's Leiter score. Now, when we introduced the variable of meeting 1-2-3. What we mean screened by one month, identified at two months and in early intervention at three months. Meeting one, two, three accounted on its own for 6.2 percent of the variance. After controlling for cognitive scores and degree of hearing loss, it dropped to 4.3 percent. But what was most interesting is that meeting one, two, three was less related to hearing loss, which is good for newborn hearing screening program in Colorado and to the Leiter score and to maternal level of education. So that means regardless of your degree of hearing loss, your Leiter cognitive score or your maternal level of education, you are pretty equally likely to meet one, two, three at least in the state of Colorado. So when you see, if you meet just by looking at that single variable of meeting one, two, three, the children at 84 months were performing over 90 months on this. Again, these children were all pretty early identified but for the children who didn't meet one, two, three and were more in the one, three, six category, they were pretty close to age level versus being above age level. When we added all of those in, maternal level of education, cognitive score and meeting one, two, three, the other thing that happened is that the maternal level of education dropped at a significant predictor. That is why I am saying that as much as possible systems -- especially for the at risk population should strive to deliver services as early as possible. The parent word per minute is something we have complete control over in terms of early intervention services. We can teach parents good communication strategies. The parent word per minute accounted for 11.6 percent of the variance. It did lose some significance when we accounted for Leiter scores and degree of hearing loss. And that is because Leiter scores are related to a higher level of conversation.  Actually maternal level of education is related to a higher level of conversation in the home. And when maternal -- when words per minute is added with maternal level of education, it loses its sickness as a predictor of outcome at 84 months of age. Teaching parents good conversation strategies is a counter to lower levels of maternal level of education. You can see here at the parent word frequency what you see is that when we are highly, highly successful, in other words, the word frequency for those parents is at the upper 25th percentile, the children at 84 months were right at age level. Now, another way of graphing this is to show at the bottom is the lower quartile of parent talking. The interquartile, the median quartile and the upper quartile. And the two bars represent low maternal level of education and that is in the dark bars.  And the lighter bars are the higher maternal level of education. And the breaking point here is high school and below versus some college. What is really interesting is that the upper quartile you can see if parented learn how to talk to use a lot of good strategies for communication, there is no difference between the two groups by maternal level of education. We were a bit puzzled that there is a difference in the median quartile and the lower quartile for the parents who have high school level of education or below. But not for the parents who have college education. So apparently, the parents who have higher levels of education are somehow supplementing even when they are talking less to their children. And it may be that they are accessing higher quantity of services. We don't actually know why the parents with higher level of education, we see less of an affect by the communication strategies that we are using. We also looked at the actual expressive language quotient at 36 months. It accounted for 27.4 percent of variance on outcome. After controlling for hearing loss and Leiter, it dropped to about five percent of the variance.  But it is still accounting for a significant amount of the variance in the expressive one word picture outcomes at 84 months of age. The children who at three years of age were within the normal range on their Minnesota expressive language quotient at 84 months of age, those children longitudinally and their expressive one word picture vocabulary test was at age level.  The best odds at staying at age level when you look across the broad population is to meet 1-2-3 and to teach good conversation strategies in early intervention. Each variable increases the growth rate of vocabulary teaching parent better communication strategies. We certainly can control the quality of our early intervention strategies. But we can't control whether or not people have mild hearing loss or profound hearing loss or they have higher cognitive ability or lower cognitive ability. And just to give you just a little bit more information on how important those conversational strategies are early on, there has been an enormous amount of research productivity. Looking at the relationship between conversational terms and in this study the Noble, Houston, and Kan, they were -- what you see in this figure is that there is greater activity in the language processing centers of the brain when there is greater number of conversational turns between parent and child.  And this particular area of the brain that is activated drives brain processing speed and it is the that processing speed that -- there is a causal relationship there between what is happening in the activation of the language centers of the brain and the acquisition of vocabulary. And this is not surprising to any of you who are listening to this presentation. We see that the synaptic growth in the brain over time is unbelievably connected. They build millions of neural connections per second. By the time they are three years of eamg, those synaptic connection grow to 8 -- age, those si you look at the growth. By two years it is incredibly dense and that is really amazing actually what happens in the neural system. As children get to that two to three year period still millions of connections happening, there is a pruning system that happens and it is related to the native language. So skills that the children had in the newborn period where they could access all of sounds of all of the languages in the world are no longer as important in the child. We see them pruning in their ability so they are really focusing on the native language that they are hearing. Typically developing children, there was  a longitudinal study using the LENA Foundation device in the early years and a number of both the child cognitive scores, their verbal language, and their reading proficiency at 12 years of age.  Now, this is in typically developing children. And again, what I was showing you in the four to seven, is that appears to be very comparable to what we are seeing in the children who are deaf and hard of hearing. Now, if you are interested in this literature which is really fascinating and I probably haven't up dated it enough to know there are new articles that are being published all the time, you can go to the LENA website and they keep that website very up-to-date. But these articles are fascinating. And they are definitely showing that when parents increase the number of conversational terms to their children in the early years, it has a direct affect on the brain activity in the language centers. So thank you very much. And at this point in time I am happy to take any questions that you might have. 

>>Kate: There aren't any at the moment. But we can see if any come in. Might have time for just a couple. All right. While we wait, unless Christine, did you have something else you wanted to say? 

>>Yoshinaga-Itano: I was going to say that this article, I couldn't give you actually all the publication figures and the reason I couldn't give it to you is because it is in press now in pediatrics and it is scheduled hopefully -- we are hoping at the end of September, beginning of October, that it will be actually in publication and then you can access the full article. But this is really the first evidence that we have of the impact of universal newborn hearing screening on a long term basis, not just in early childhood but throughout the entire educational progress of the children. And there were children -- so I am looking at the chat right now. There is a question about are there any articles or references that you can share regarding children who are ASL users and their late of language. We published an article on children who had access to sign language instruction and that sign language instruction was with ASL. So the difficulty with answering this question is that even when parents are learning ASL, that doesn't necessarily mean that they are using a really high quality ASL communication system with their children and that the children are using the same ASL developmentally as if they were deaf of deaf children because most of these families are second language users of ASL and they -- they are learning it. So they are not as proficient when they first begin using it as when they have three years or more of instruction. But we certainly show some remarkable gains in children who were ASL users. Many of them ended up later get a cochlear implant.