What do Speech-Language Pathologists want to know when assessing early vocal development in children who are deaf/hard-of-hearing?

PURPOSE: Delays in vocal development are an early predictor of ongoing language difficulty for children who are deaf/hard-of-hearing (CDHH). Despite the importance of monitoring early vocal development in clinical practice, there are few suitable tools. This study aimed to identify the clinical decisions that speech-language pathologists (SLPs) most want to make when assessing vocal development and their current barriers to doing so. METHOD: 58 SLPs who provide services to CDHH younger than 22 months completed a survey. The first section measured potential barriers to vocal development assessment. The second section asked SLPs to rate the importance of 15 clinical decisions they could make about vocal development. RESULTS: SLPs believed assessing vocal development was important for other stakeholders, and reported they had the necessary skills and knowledge to assess vocal development. Barriers primarily related to a lack of commercially available tests. SLPs rated all 15 clinical decisions as somewhat or very important. Their top 5 decisions included a variety of assessment purposes that tests are not typically designed to support, including measuring change, differential diagnosis, and goal setting. CONCLUSIONS: SLPs wish to make a number of clinical decisions when assessing vocal development in CDHH but lack access to appropriate tools to do so. Future work is needed to develop tools that are statistically equipped to fulfill these purposes. Understanding SLPs' assessment purposes will allow future tests to better map onto the clinical decisions that SLPs need to make to support CDHH and their families and facilitate implementation into clinical practice.

Adopting a Conceptual Validity Framework for Testing in Speech-Language Pathology.

Purpose Limited evidence-based guidelines for test selection continue to result in inconsistency in test use and interpretation in speech-language pathology. A major barrier is the lack of explicit and consistent adoption of a validity framework by our field. In this viewpoint, we argue that adopting the conceptual validity framework in the Standards for Educational and Psychological Testing (American Educational Research Association et al., 2014) would support both the development of more meaningful and feasible clinical tests and more appropriate use and interpretation of tests in speech-language pathology. Method We describe and evaluate the Standards for Educational and Psychological Testing (American Educational Research Association et al., 2014) validity framework and consider its relevance to speech-language pathology. We describe how the validity framework could be integrated into clinical practice and include examples of how it could be applied to support common clinical decisions. We evaluate the costs and benefits of adopting this framework, from the perspectives of speech-language pathologists, clients, and test developers. Results The Standards' validity framework clarifies complex validity issues by shifting the focus of validity from tests to the decisions speech-language pathologists make based on test results. By focusing on decisions, the framework requires critical evaluation of test use, rather than evaluating tests against sets of criteria. Adopting this framework has the potential for appreciable improvement in the way tests are used and valued across our profession. Conclusions Speech-language pathologists, test developers, and clients will benefit from improved evidence-based assessment practices. It is recommended that regulators, test developers, professional associations, universities, and researchers adopt the framework and endorse it as best practice moving forward. This viewpoint proposes a series of first steps toward supporting uptake of the framework into research and practice.

Validity Evidence for the LittlEARS Early Speech Production Questionnaire: An English-Speaking, Canadian Sample.

Purpose This study reports validity evidence for an English translation of the LittlEARS Early Speech Production Questionnaire (LEESPQ). The LEESPQ was designed to support early spoken language outcome monitoring in young children who are deaf/hard of hearing. Methods Data from 90 children with normal hearing, ages 0-18 months, are reported. Parents completed the LEESPQ in addition to a concurrent measure of spoken language development, the Receptive-Expressive Emergent Language Test-Third Edition. Normal hearing status and development were confirmed. Results Traditional scale analyses, in addition to item parameters, are reported. The LEESPQ was highly correlated with the Receptive-Expressive Emergent Language Test-Third Edition (r = .92) and age (r = .90) and had high internal consistency (Ω = 0.92). Common factor analysis revealed 2 underlying factors conceptually mapping onto items measuring vocal and symbolic development. A latent traits model was the best fit to the data, and item difficulty broadly conformed to theoretical expectations. Conclusions The present work demonstrates that the LEESPQ accurately captures early spoken language development in a typically developing group of young children. The LEESPQ holds promise as a clinically feasible, spoken language outcome monitoring tool. Future work to identify differences in performance characteristics between typically developing children and clinical populations is warranted.

A Comment on Test Validation: The Importance of the Clinical Perspective.

Purpose The misuse of standardized assessments has been a long-standing concern in speech-language pathology and traditionally viewed as an issue of clinician competency and training. The purpose of this article is to consider the contribution of communication breakdowns between test developers and the end users to this issue. Method We considered the misuse of standardized assessments through the lens of the 2-communities theory, in which standardized tests are viewed as a product developed in 1 community (researchers/test developers) to be used by another community (frontline clinicians). Under this view, optimal test development involves a conversation to which both parties bring unique expertise and perspectives. Results Consideration of the interpretations that standardized tests are typically validated to support revealed a mismatch between these and the interpretations and decisions that speech-language pathologists typically need to make. Test development using classical test theory, which underpins many of the tests in our field, contributes to this mismatch. Application of item response theory could better equip clinicians with the psychometric evidence to support the interpretations they desire but is not commonly found in the standardized tests used by speech-language pathologists. Conclusions Advocacy and insistence on the consideration of clinical perspectives and decision making in the test validation process is a necessary part of our role. In improving the nature of the statistical evidence reported in standardized assessments, we can ensure these tools are appropriate to fulfill our professional obligations in a clinically feasible way.

Language Outcomes in Children Who Are Deaf and Hard of Hearing: The Role of Language Ability Before Hearing Aid Intervention.

Purpose: Early auditory experiences are fundamental in infant language acquisition. Research consistently demonstrates the benefits of early intervention (i.e., hearing aids) to language outcomes in children who are deaf and hard of hearing. The nature of these benefits and their relation with prefitting development are, however, not well understood. Method: This study examined Ontario Infant Hearing Program birth cohorts to explore predictors of performance on the Preschool Language Scale-Fourth Edition at the time of (N = 47) and after (N = 19) initial hearing aid intervention. Results: Regression analyses revealed that, before the hearing aid fitting, severity of hearing loss negatively predicted 19% and 10% of the variance in auditory comprehension and expressive communication, respectively. After hearing aid fitting, children's standard scores on language measures remained stable, but they made significant improvement in their progress values, which represent individual skills acquired on the test, rather than standing relative to same-age peers. Magnitude of change in progress values was predicted by a negative interaction of prefitting language ability and severity of hearing loss for the Auditory Comprehension scale. Conclusions: These findings highlight the importance of considering a child's prefitting language ability in interpreting eventual language outcomes. Possible mechanisms of hearing aid benefit are discussed. Supplemental Materials: https://doi.org/10.23641/asha.5538868.

Fit-to-Targets for the Desired Sensation Level Version 5.0a Hearing Aid Prescription Method for Children.

PURPOSE: The purpose of this study was to measure the range of fit to Desired Sensation Level version 5.0 (DSL v5.0) targets in pediatric practice environments. Results will be used in the future to develop clinical-aided speech intelligibility index typical performance data. METHOD: Clinical partners collected data from 161 final hearing aid settings for children aged ≤ 10 years. Measured data were obtained by performing 2-cm3 coupler-simulated real-ear measurements using the DSL v5.0 implementation on the Audioscan VF-1 (Etymonic Design Inc., Dorchester, ON, Canada) for soft, average, and loud speech inputs and maximum hearing aid output levels. RESULTS: Fittings were within ± 5-dB root-mean-square (RMS) error of target for 77%, 80%, and 82% of fittings for the soft, medium, and loud speech test levels, respectively. Aided maximum power output measures were within ± 5-dB RMS error in 72% of cases. Degree of hearing loss, test frequency, and frequency by test level were significant factors in deviation from target. The range of aided speech intelligibility index values exhibited a strong correlation with the hearing levels of the children tested. CONCLUSION: This study provides evidence that typical hearing aid fittings for children can be achieved within ± 5-dB RMS error of the DSL v5.0 target. Greater target deviations were observed at extreme frequencies and as the severity of hearing loss increased.

Relevance of the International Classification of Functioning, Health and Disability: Children & Youth Version in Early Hearing Detection and Intervention Programs.

Early hearing detection and intervention (EHDI) programs have been guided by principles from the Joint Committee on Infant Hearing and an international consensus of best practice principles for family-centered early intervention. Both resources provide a solid foundation from which to design, implement, and sustain a high-quality, family-centered EHDI program. As a result, infants born with permanent hearing loss and their families will have the support they need to develop communication skills. These families also will benefit from programs that align with the framework offered by the World Health Organization's International Classification of Functioning, Disability and Health: Children & Youth Version (ICF-CY). Within this framework, health and functioning is defined and measured by describing the consequences of the health condition (i.e., hearing loss) in terms of body function, structures, activity, and participation as well as social aspects of the child. This article describes the relevance of the ICF-CY for EHDI programs and offers a modified approach by including aspects of quality of life and human development across time.

Validation of the Parents' Evaluation of Aural/Oral Performance of Children (PEACH) Rating Scale.

BACKGROUND: The Parents' Evaluation of Aural/Oral Performance of Children (PEACH) is a caregiver report questionnaire that is suitable for use with children who wear hearing aids. It is available in both a Diary format and a Rating Scale format. Following a critical review of subjective outcome evaluation tools for infants, toddlers, and preschool children (Bagatto, Moodie, Seewald et al, 2011), the Rating Scale version of the PEACH was included in a recently developed guideline for monitoring real-world auditory performance of children who have hearing loss (Bagatto, Moodie, Malandrino et al, 2011). Normative data exist only for the PEACH Diary, not the Rating Scale. PURPOSE: This article evaluates whether published normative data for the PEACH Diary (Ching and Hill, 2007) are replicated on a different sample of children using the PEACH Rating Scale. RESEARCH DESIGN: Fifty-nine children with normal hearing aged 2 mo to 83 mo and their primary caregivers participated in the study. Caregivers completed the PEACH Rating Scale for each child with normal hearing. RESULTS: Results indicated close agreement to existing normative data collected with the PEACH Diary, with no differences in scores between males and females and good internal consistency. Age-related trends published for the Diary version were replicated using the Rating Scale version, as significantly lower scores were observed for children 20 mo of age and younger compared to those older than 20 mo of age. CONCLUSIONS: The currently published norms for the PEACH Diary are valid for use with the PEACH Rating Scale with caregivers of normal hearing children. This validation work adds to the evidence base of the PEACH Rating Scale and supports its use in clinical practice.

Knowledge translation in audiology: promoting the clinical application of best evidence.

The impetus for evidence-based practice (EBP) has grown out of widespread concern with the quality, effectiveness (including cost-effectiveness), and efficiency of medical care received by the public. Although initially focused on medicine, EBP principles have been adopted by many of the health care professions and are often represented in practice through the development and use of clinical practice guidelines (CPGs). Audiology has been working on incorporating EBP principles into its mandate for professional practice since the mid-1990s. Despite widespread efforts to implement EBP and guidelines into audiology practice, gaps still exist between the best evidence based on research and what is being done in clinical practice. A collaborative dynamic and iterative integrated knowledge translation (KT) framework rather than a researcher-driven hierarchical approach to EBP and the development of CPGs has been shown to reduce the knowledge-to-clinical action gaps. This article provides a brief overview of EBP and CPGs, including a discussion of the barriers to implementing CPGs into clinical practice. It then offers a discussion of how an integrated KT process combined with a community of practice (CoP) might facilitate the development and dissemination of evidence for clinical audiology practice. Finally, a project that uses the knowledge-to-action (KTA) framework for the development of outcome measures in pediatric audiology is introduced.

An integrated knowledge translation experience: use of the Network of Pediatric Audiologists of Canada to facilitate the development of the University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP v1.0).

Pediatric audiologists lack evidence-based, age-appropriate outcome evaluation tools with well-developed normative data that could be used to evaluate the auditory development and performance of children aged birth to 6 years with permanent childhood hearing impairment. Bagatto and colleagues recommend a battery of outcome tools that may be used with this population. This article provides results of an evaluation of the individual components of the University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP) version 1.0 by the audiologists associated with the Network of Pediatric Audiologists of Canada. It also provides information regarding barriers and facilitators to implementing outcome measures in clinical practice. Results indicate that when compared to the Parents' Evaluation of Aural/Oral Performance of Children (PEACH) Diary, audiologists found the PEACH Rating Scale to be a more clinically feasible evaluation tool to implement in practice from a time, task, and consistency of use perspective. Results also indicate that the LittlEARS(®) Auditory Questionnaire could be used to evaluate the auditory development and performance of children aged birth to 6 years with permanent childhood hearing impairment (PCHI). The most cited barrier to implementation is time. The result of this social collaboration was the creation of a knowledge product, the UWO PedAMP v1.0, which has the potential to be useful to audiologists and the children and families they serve.

The University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP).

This study proposed and evaluated a guideline for outcome evaluation for infants and children with hearing loss who wear hearing aids. The University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP) was developed following a critical review of pediatric outcome evaluation tools and was systematically examined by the Network of Pediatric Audiologists of Canada. It consists of tools to gather clinical process outcomes as well as functional caregiver reports. The UWO PedAMP was administered to a clinical population of infants and children with hearing aids. Sixty-eight children were administered the functional outcome evaluation tools (i.e., caregiver reports) a total of 133 times. Clinical process outcomes of hearing aid verification (e.g., real-ear-to-coupler difference) revealed typical aided audibility (e.g., Speech Intelligibility Index). Results for the LittlEARS(®) questionnaire revealed that typically developing children with hearing loss who wear hearing aids are meeting auditory development milestones. Children with mild to moderate comorbidities displayed typical auditory development during the 1st year of life after which development began to decline. Children with complex factors related to hearing aid use had lower scores on the LittlEARS, but auditory development was in parallel to norms. Parents' Evaluation of Aural/Oral Performance (PEACH) results indicated no age effect on scoring for children above 2 years of age; however, the effect of degree of hearing loss was significant. This work provides clinicians with a systematic, evidence-based outcome evaluation protocol to implement as part of a complete pediatric hearing aid fitting.

A critical review of audiological outcome measures for infants and children.

Outcome evaluation is an important stage in the pediatric hearing aid fitting process, however a systematic way of evaluating outcome in the pediatric audiology population is lacking. This is in part due to the need for an evidence-based outcome evaluation guideline for infants and children with hearing loss who wear hearing aids. As part of the development of a guideline, a critical review of the existing pediatric audiology outcome evaluation tools was conducted. Subjective outcome evaluation tools that measure auditory-related behaviors in children from birth to 6 years of age were critically appraised using a published grading system (Andresen, 2000). Of the tools that exist, 12 were appraised because they met initial criteria outlined by the Network of Pediatric Audiologists of Canada as being appropriate for children birth to 6 years of age who wear hearing aids. Tools that were considered for the guideline scored high in both statistical and feasibility criteria. The subjective outcome evaluation tools that were ultimately chosen to be included in the guideline were the LittlEARS Auditory Questionnaire (Tsiakpini et al., 2004) and the Parents' Evaluation of Aural/Oral Performance of Children (PEACH) Rating Scale (Ching & Hill, 2005b) due to the high grades they received in the critical review and their target age ranges. Following this critical review of pediatric outcome evaluation tools, the next step was for the Network Clinicians to evaluate the guideline (Moodie et al., 2011b).

External validation of the LittlEARS® Auditory Questionnaire with English-speaking families of Canadian children with normal hearing.

OBJECTIVE: To examine the external validity of the United Kingdom English version of the LittlEARS(®) Auditory Questionnaire with English-speaking families of Canadian children with normal hearing. METHODS: The United Kingdom English version of the LittlEARS was administered to English-speaking families of 130 children with normal hearing in Ontario, Canada. Total scores for these children were compared to German-derived normative values. RESULTS: There was no significant difference between Canadian and German norms when using the United Kingdom English version of the LittlEARS Auditory Questionnaire. CONCLUSIONS: The United Kingdom English version of the LittlEARS Auditory Questionnaire is appropriate for use with English-speaking families of normal hearing Canadian children.

Evaluation of the desired sensation level [input/output] algorithm for adults with hearing loss: the acceptable range for amplified conversational speech.

OBJECTIVES: This study had two related purposes: first, to define the range of optimal ear canal levels of aided speech in both high frequency and low frequency regions for adults, using both subjective and objective definitions of optimal; and second, to determine whether a prescribed frequency response, such as that given by Desired Sensation Level [Input/Output], falls within the adult listener's optimal range. DESIGN: Twenty-three adult listeners with mild to moderately severe sensorineural hearing loss were selected from a pool of research volunteers. They were fitted in the laboratory with the Siemens Signia hearing instrument and tested with 20 nominally different frequency responses. All advanced processing options of the hearing instrument were disabled. Subjective ratings of loudness and quality and objective measures of consonant identification were obtained for every frequency response. RESULTS: These adult listeners had, on average, a 10 dB range of measured responses in both the low and the high frequencies that resulted in optimal performance on all the measurements. The range did not vary with degree or configuration of hearing loss, or previous hearing aid experience. Desired-Sensation-Level Input/Output targets were within the optimal range for the low frequencies, and 3 dB above the optimal range for the high frequencies. CONCLUSIONS: A range of aided ear canal frequency responses was determined within which adults with mild to moderately severe hearing loss performed optimally on both objective and subjective outcomes. Clinical implications of this finding include the following: prescriptive methods providing different targets may all result in optimal fittings; and a range of targets may be more appropriate than a single target when setting the frequency-gain characteristics of the hearing instrument.

Evaluation of a probe-tube insertion technique for measuring the real-ear-to-coupler difference (RECD) in young infants.

A common strategy for measuring the real-ear response of the real-ear-to-coupler difference (RECD) in the pediatric population is to insert a probe-tube separately from the eartip. This strategy is at times difficult to implement while attempting to obtain the measurement from a young infant. An RECD probe-tube insertion technique that involves connecting the probe-tube to an eartip with plastic film for simultaneous insertion was examined on 30 infants. Repeated measurements were completed on each infant to obtain within-session test-retest reliability data. Probe-tube insertion depth was also examined across participants to provide a guideline for the infant population. Findings indicate that reliable RECD values can be obtained in infants when the probe-tube is extended approximately two to four millimeters (mm) beyond the eartip or 11 mm from the entrance to the ear canal. Clinical implications of this work are discussed.

Real-ear-to-coupler difference predictions as a function of age for two coupling procedures.

The predicted real-ear-to-coupler difference (RECD) values currently used in pediatric hearing instrument prescription methods are based on 12-month age range categories and were derived from measures using standard acoustic immittance probe tips. Consequently, the purpose of this study was to develop normative RECD predicted values for foam/acoustic immittance tips and custom earmolds across the age continuum. To this end, RECD data were collected on 392 infants and children (141 with acoustic immittance tips, 251 with earmolds) to develop normative regression equations for use in deriving continuous age predictions of RECDs for foam/acoustic immittance tips and earmolds. Owing to the substantial between-subject variability observed in the data, the predictive equations of RECDs by age (in months) resulted in only gross estimates of RECD values (i.e., within +/- 4.4 dB for 95% of acoustic immittance tip measures; within +/- 5.4 dB in 95% of measures with custom earmolds) across frequency. Thus, it is concluded that the estimates derived from this study should not be used to replace the more precise individual RECD measurements. Relative to previously available normative RECD values for infants and young children, however, the estimates derived through this study provide somewhat more accurate predicted values for use under those circumstances for which individual RECD measurements cannot be made.