Coalition for Global Hearing Health Hearing Care Pathways Working Group: Guidelines for Clinical Guidance for Readiness and Development of Evidence-Based Early Hearing Detection and Intervention Programs.

Editor's Note: The following article discusses the timely topic Clinical Guidance in the areas of Evidence-Based Early Hearing Detection and Intervention Programs. This article aims to discuss areas of services needed, guidance to countries/organizations attempting to initiate early hearing detection and intervention systems. Expert consensus and systematic/scoping reviews were combined to produce recommendations for evidence-based clinical practice. In Ear and Hearing, our long-term goal for the Point of View article is to stimulate the field's interest in and to enhance the appreciation of the author's area of expertise. Hearing is an important sense for children to develop cognitive, speech, language, and psychosocial skills. The goal of universal newborn hearing screening is to enable the detection of hearing loss in infants so that timely health and educational/therapeutic intervention can be provided as early as possible to improve outcomes. While many countries have implemented universal newborn hearing screening programs, many others are yet to start. As hearing screening is only the first step to identify children with hearing loss, many follow-up services are needed to help them thrive. However, not all of these services are universally available, even in high-income countries. The purposes of this article are (1) to discuss the areas of services needed in an integrated care system to support children with hearing loss and their families; (2) to provide guidance to countries/organizations attempting to initiate early hearing detection and intervention systems with the goal of meeting measurable benchmarks to assure quality; and (3) to help established programs expand and improve their services to support children with hearing loss to develop their full potential. Multiple databases were interrogated including PubMed, Medline (OVIDSP), Cochrane library, Google Scholar, Web of Science and One Search, ERIC, PsychInfo. Expert consensus and systematic/scoping reviews were combined to produce recommendations for evidence-based clinical practice. Eight essential areas were identified to be central to the integrated care: (1) hearing screening, (2) audiologic diagnosis and management, (3) amplification, (4) medical evaluation and management, (5) early intervention services, (6) family-to-family support, (7) D/deaf/hard of hearing leadership, and (8) data management. Checklists are provided to support the assessment of a country/organization's readiness and development in each area as well as to suggest alternative strategies for situations with limited resources. A three-tiered system (i.e., Basic, Intermediate, and Advanced) is proposed to help countries/organizations at all resource levels assess their readiness to provide the needed services and to improve their integrated care system. Future directions and policy implications are also discussed.

A validation and normative study of the Parents' Evaluation of Aural/Oral Performance of Children plus (PEACH+) rating scale in Malaysia.

OBJECTIVE: The purpose of the present study was to (1) translate and validate the PEACH + Rating Scale in Malay and (2) establish normative curves as a function of age and examine test-retest reliability for the Malay and English versions of PEACH+. DESIGN: This is a cross-sectional study that used a convenient sampling technique. STUDY SAMPLE: One hundred and fifty-seven parents of typically developing children aged between 4 months and 7 years participated in the study. Forty-nine completed the Malay PEACH + in a pen-to-paper format (Aim 1). One hundred and eight parents completed PEACH + online (69 completed the Malay version and 39 the English version), and 20 of them completed the questionnaire twice (Aim 2). RESULTS: The PEACH + in Malay showed high internal consistency and item-total correlation. The normative data revealed that scores for frequency of auditory behaviour increased rapidly with age until about 20 months and reached an asymptote of around 90% by about 40 months of age. A similar trend was observed for ease of listening scores, which asymptoted around 85%. CONCLUSIONS: The validated Malay PEACH + Rating Scale can be used as a guide to monitor auditory functional performance and listening efforts of Malaysian children in real-world environments.

Development and Evaluation of a Language-Independent Test of Auditory Discrimination for Referrals for Cochlear Implant Candidacy Assessment.

OBJECTIVES: The purpose of this study was to (1) develop a Language-independent Test of Auditory Discrimination (LIT-AD) between speech sounds so that people with hearing loss who derive limited speech perception benefits from hearing aids (HAs) may be identified for consideration of cochlear implantation and (2) examine the relationship between the scores for the new discrimination test and those of a standard sentence test for adults wearing either HAs or cochlear implants (CIs). DESIGN: The test measures the ability of the listener to correctly discriminate pairs of nonsense syllables, presented as sequential triplets in an odd-one-out format, implemented as a game-based software tool for self-administration using a tablet computer. Stage 1 included first a review of phonemic inventories in the 40 most common languages in the world to select the consonants and vowels. Second, discrimination testing of 50 users of CIs at several signal to noise ratios (SNRs) was carried out to generate psychometric functions. These were used to calculate the corrections in SNR for each consonant-pair and vowel combination required to equalize difficulty across items. Third, all items were individually equalized in difficulty and the overall difficulty set. Stage 2 involved the validation of the LIT-AD in English-speaking listeners by comparing discrimination scores with performance in a standard sentence test. Forty-one users of HAs and 40 users of CIs were assessed. Correlation analyses were conducted to examine test-retest reliability and the relationship between performance in the two tests. Multiple regression analyses were used to examine the relationship between demographic characteristics and performance in the LIT-AD. The scores of the CI users were used to estimate the probability of superior performance with CIs for a non-CI user having a given LIT-AD score and duration of hearing loss. RESULTS: The LIT-AD comprises 81 pairs of vowel-consonant-vowel syllables that were equalized in difficulty to discriminate. The test can be self-administered on a tablet computer, and it takes about 10 min to complete. The software automatically scores the responses and gives an overall score and a list of confusable items as output. There was good test-retest reliability. On average, higher LIT-AD discrimination scores were associated with better sentence perception for users of HAs (r = -0.54, p <0.001) and users of CIs (r = -0.73, p <0.001). The probability of superior performance with CIs for a certain LIT-AD score was estimated, after allowing for the effect of duration of hearing loss. CONCLUSIONS: The LIT-AD could increase access to CIs by screening for those who obtain limited benefits from HAs to facilitate timely referrals for CI candidacy evaluation. The test results can be used to provide patients and professionals with practical information about the probability of potential benefits for speech perception from cochlear implantation. The test will need to be evaluated for speakers of languages other than English to facilitate adoption in different countries.

An Economic Evaluation of Australia's Newborn Hearing Screening Program: A Within-Study Cost-Effectiveness Analysis.

OBJECTIVES: Hearing loss is one of the most prevalent congenital disorders among children. Many countries have implemented universal newborn hearing screening (UNHS) for the early diagnosis and treatment of hearing loss. Despite widespread implementation, the value for money of UNHS is unclear due to lack of cost and outcomes data from rigorous study designs. The objective of this research is to conduct a within-study cost-effectiveness analysis of UNHS compared with targeted screening (targeting children with risk factors of hearing loss) from the Australian healthcare system perspective. This evaluation is the first economic evaluation to assess the cost-effectiveness of UNHS compared to targeted screening using real-world data from a natural experiment. DESIGN: The evaluation assumed the Australian healthcare system perspective and considered a time horizon of 5 years. Utilities were estimated using responses to the Health Utilities Index Mark III. Screening costs were estimated based on the Victorian Infant Hearing Screening Program. Ongoing costs were estimated based on administrative data, while external data sources were used to estimate costs related to hearing services. Missing data were handled using the multiple imputation method. Outcome measures included quality-adjusted life years (QALYs) and four language and communication-related outcomes: Peabody Picture Vocabulary Test, Wechsler Nonverbal Scale of Ability, Progressive Achievement Test, and comprehensive, expressive, and total language scores based on the Preschool Language Scale. RESULTS: On average, the UNHS cost an extra Australian dollar (A$)22,000 per diagnosed child and was associated with 0.45 more QALYs per diagnosed child compared with targeted screening to 5 years, resulting in an incremental cost-effectiveness ratio (ICER) of A$48,000 per QALY gained. The ICERs for language outcomes lay between A$3,900 (for expressive language score) and A$83,500 per one-point improvement in language score (for Wechsler Nonverbal Scale of Ability). UNHS had a 69% probability of being more cost-effective compared to targeted screening at a willingness to pay threshold of A$60,000 per QALY gained. ICERs were most sensitive to the screening costs. CONCLUSIONS: The evaluation demonstrated the usefulness of a within-study economic evaluation to understand the value for money of the UNHS program in the Australian context. Findings from this evaluation suggested that screening costs were the key driver of cost-effectiveness results. Most outcomes were not significantly different between UNHS and targeted screening groups. The ICER may be overestimated due to the short follow-up period. Further research is warranted to include long-term resource use and outcome data, late diagnosis, transition and remission between severity levels, and timing of diagnosis and treatment.

The Chinese version of the Parents' Evaluation of Aural/Oral Performance of Children (PEACH) rating scale for infants and children with normal hearing.

OBJECTIVE: This study aimed to establish Chinese norms for the Chinese version of the Parent's Evaluation of Aural/Oral of Children (PEACH) rating scale. DESIGN AND STUDY SAMPLE: The PEACH scores were collected from 198 parents whose children have normal hearing. The test-retest reliability of the PEACH scale was evaluated in a subgroup of 34 parents. Another 27 parents also filled out a Putonghua Communicative Development Inventory which was used to explore the relationship between the PEACH ratings and language scores. RESULTS: The normative curve was established using a logit regression function. The total scores increase rapidly with increasing age. A plateau starts from 22 months with the PEACH score reaching 90% and achieves the maximum score of 95% by 47 months of age. The test-retest analyses showed high reliability for all subscales, with all the correlation coefficients values exceeding 0.9 (p < 0.01). The 90% and 95% confidence intervals were provided to facilitate evaluation of differences between scores obtained under different conditions. A significant correlation was found between the PEACH total score and language performance (p < 0.05). CONCLUSIONS: Normative data from the Chinese population was provided to enable performance of an individual child to be related to their normally hearing peers.

Mild matters: parental insights into the conundrums of managing mild congenital hearing loss.

OBJECTIVE: To explore and describe parental experiences related to the management of mild bilateral congenital hearing loss in children. DESIGN: Using qualitative methods, we conducted semi-structured interviews with parents/caregivers until saturation of themes was achieved. We analysed transcripts using inductive content analysis. STUDY SAMPLE: Caregivers of children under 3-years-old with mild bilateral sensorineural hearing loss. RESULTS: We interviewed 12 parents. Parental perception of advice regarding hearing aid fitting was varied; almost all children were offered hearing aids. Perceived positives related to hearing aids: feeling empowered that action has been taken; improvements in the child's hearing perception and; facilitation of behavioural management. Perceived negatives of hearing aid use: difficulties with compliance resulting in parental frustration and guilt, damage/loss of equipment, discomfort, parental discord, altered quality of natural sound and potential bullying/stigma. Some parents were ambivalent about the effect of the hearing aids. Where hearing aids were offered and not fitted, there was significant ongoing uncertainty, and the family carried the burden of their decision. CONCLUSIONS: There was a wide variation in perceived advice regarding early hearing aid fitting in children with mild bilateral hearing loss. We identified parental perceptions of positive/negative impacts of hearing aid fitting and potential perceived harms from not fitting.

Audiologists' perspectives on management of mild bilateral hearing loss in infants and young children.

OBJECTIVE: Universal newborn hearing screening programs have led to early identification of infants with congenital mild bilateral hearing loss (MBHL). The current lack of evidence-based protocols to guide audiological management of infants with MBHL has led to clinical equipoise about fitting of hearing aids. The purpose of this study was to increase understanding about the perspectives of paediatric audiologists on factors influencing their management of MBHLin infants and young children. DESIGN: A qualitative descriptive research methodology involving semi-structured interviews with audiologists. STUDY SAMPLE: Twenty-three paediatric audiologists in diagnostic and rehabilitation settings in Victoria, Australia. RESULTS: Three main themes that influenced management were identified. These include: (1) evidence, or the lack of it, influences audiologists' practice; (2) audiologists recognise the need to be fluid; and (3) family characteristics and parents' perspectives. "Audiologists delivering family-centred practice" was identified as an overarching theme across these factors. CONCLUSIONS: Audiologists recognised the importance of adopting a family-centred approach in their management of MBHL in infants and young children. Embodied in their practice was the acknowledgement of limited evidence, the consideration of multiple child and family factors, and the incorporation of perspectives of parents and families in adopting a fluid approach to provide individualised services.

Maternal education influences Australian infants' language experience from six months.

Disparities in children's early language skills associated with socioeconomic factors have led to many studies examining children's early language environments, but few as yet in the first year of life. This longitudinal study assessed the home language environments of 50 Australian infants, who varied in maternal education (university education, or not). Full-day audio recordings were collected and analyzed using the LENA system when infants were aged 6-9 months and 12-15 months. Using the device-specific analysis software, we assessed 12-h projected counts of (1) adult speech input, (2) conversational interactions, and (3) child vocalizations. At both ages, higher maternal education was associated with higher counts of adult words and conversational turns, but not child vocalizations. The study adds to the literature by demonstrating disparities in the infants' language experience within the first year of life, related to mothers' education, with implications for early intervention and parenting supports.

Learning from the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study: summary of 5-year findings and implications.

OBJECTIVE: This article summarises findings of the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study, and discusses implications of the findings for research and clinical practice. DESIGN: A population-based study on outcomes of children with hearing loss. Evaluations were conducted at five years of age. STUDY SAMPLE: Participants were 470 children born with hearing loss between 2002 and 2007 in New South Wales, Victoria and Queensland in Australia, and who first received amplification or cochlear implantation by three years of age. RESULTS: The earlier hearing aids or cochlear implants were fitted, the better the speech, language and functional performance outcomes. Better speech perception was also associated with better language and higher cognitive abilities. Better psychosocial development was associated with better language and functional performance. Higher maternal education level was also associated with better outcomes. Qualitative analyses of parental perspectives revealed the multiple facets of their involvement in intervention. CONCLUSIONS: The LOCHI study has shown that early fitting of hearing devices is key to achieving better speech, language and functional performance outcomes for children with hearing loss. The findings are discussed in relation to changes in clinical practice and directions for future research.

Parental involvement in the care and intervention of children with hearing loss.

OBJECTIVE: The present study aimed to explore the nature of parental involvement in the intervention of children with hearing loss, as experienced by parents. DESIGN: A qualitative descriptive methodology was adopted to conduct semi-structured in-depth interviews with a purposive sample of parents who have a child with hearing loss. STUDY SAMPLE: Seventeen parents of 11 children aged 6-9 years participated in this study. RESULTS: The overarching theme of parents taking the central role was identified using thematic analysis. This overarching theme connected five themes which described the nature of parental involvement: (1) parents work behind the scenes; (2) parents act as 'case managers'; (3) parents always have their child's language development in mind; (4) parents' role extends to advocacy for all children with hearing loss; and (5) parents serve a number of roles, but at the end of the day, they are parents. CONCLUSIONS: The results indicate that parental involvement in the intervention of children with hearing loss is multifaceted in nature and incorporates a broad range of behaviours and practices. These findings have important implications for the provision of family-centred practices.

The parents' perspective of the early diagnostic period of their child with hearing loss: information and support.

OBJECTIVE: This study aimed to explore the perspectives of caregivers regarding the information and support they received following diagnosis of their child's hearing loss. DESIGN: A mixed methods explanatory sequential design was conducted. STUDY SAMPLE: A total of 445 caregivers of children completed a written survey, and five parents participated in qualitative in-depth interviews. RESULTS: The most common sources of information for caregivers were discussion with an audiologist, written information, and discussion with a medical professional. Approximately 85% of caregivers reported they were satisfied with the personal/emotional support and information received from service providers. Additional comments from 91 caregivers indicated that 11% experienced a breakdown in information transfer with health professionals. Interviews conducted with five parents from three families revealed two themes which described the diagnostic period as a difficult and emotional experience for parents: (1) support and information provided during diagnosis: what happens first? and (2) accessing early intervention services following a diagnosis of hearing loss: navigating the maze. CONCLUSIONS: The findings of this study give insight into the perspectives of caregivers who have a child diagnosed with hearing loss. The importance of providing timely information and personal/emotional support to caregivers cannot be underestimated.

Programming characteristics of cochlear implants in children: effects of aetiology and age at implantation.

OBJECTIVE: We investigated effects of aetiology and age at implantation on changes in threshold (T) levels, comfortable (C) levels and dynamic range (DR) for cochlear implants (CIs) in children over the first five years of life. DESIGN: Information was collected at 6 months post-activation of CIs, and at 3 and 5 years of age. STUDY SAMPLE: One hundred and sixty-one children participating in the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study. RESULTS: Children with neural and structural cochlear lesions had higher T-levels and C-levels as compared to those without these conditions. Parameter settings varied from manufacturer's defaults more often in the former than in the latter group. Investigation of the effect of age at implantation for children without neural and structural cochlear lesions showed that those implanted at ≤12 months of age had higher T-levels and narrower DR at 6 months post-activation, as compared to the later-implanted group. For both early- and later-implanted groups, the C-levels at 6 months post-activation were lower than those at age 3 and 5 years. There were no significant differences in T-levels, C-levels, or DR between age 3 and 5 years. CONCLUSIONS: Aetiology and age at implantation had significant effects on T-levels and C-levels.

Language and speech outcomes of children with hearing loss and additional disabilities: identifying the variables that influence performance at five years of age.

OBJECTIVE: This study examined language and speech outcomes in young children with hearing loss and additional disabilities. DESIGN: Receptive and expressive language skills and speech output accuracy were evaluated using direct assessment and caregiver report. Results were analysed first for the entire participant cohort, and then to compare results for children with hearing aids (HAs) versus cochlear implants (CIs). STUDY SAMPLE: A population-based cohort of 146 five-year-old children with hearing loss and additional disabilities took part. RESULTS: Across all participants, multiple regressions showed that better language outcomes were associated with milder hearing loss, use of oral communication, higher levels of cognitive ability and maternal education, and earlier device fitting. Speech output accuracy was associated with use of oral communication only. Average outcomes were similar for children with HAs versus CIs, but their associations with demographic variables differed. For HA users, results resembled those for the whole cohort. For CI users, only use of oral communication and higher cognitive ability levels were significantly associated with better language outcomes. CONCLUSIONS: The results underscore the importance of early device fitting for children with additional disabilities. Strong conclusions cannot be drawn for CI users given the small number of participants with complete data.

Hearing aid fitting and developmental outcomes of children fit according to either the NAL or DSL prescription: fit-to-target, audibility, speech and language abilities.

OBJECTIVE: This study examined the influence of prescription on hearing aid (HA) fitting characteristics and 5-year developmental outcomes of children. DESIGN: A randomised controlled trial implemented as part of a population-based study on Longitudinal Outcomes of Children with Hearing Impairment (LOCHI). STUDY SAMPLE: Two-hundred and thirty-two children that were fit according to either the National Acoustic Laboratories (NAL) or Desired Sensation Level (DSL) prescription. RESULTS: Deviation from targets and root-mean-square error in HA fitting revealed no significant difference between fitting prescriptions. Aided audibility quantified by using the Speech Intelligibility Index (SII) model showed that DSL provided higher audibility than NAL at low and medium input levels but not at high input level. After allowing for hearing loss desensitisation, differences in audibility between prescription groups were significant only at low input level. The randomised trial of prescription that was implemented for 163 children revealed no significant between-group differences in speech production, perception, and language; but parent-rated functional performance was higher for the DSL than for the NAL group. CONCLUSIONS: Proximity to prescriptive targets was similar between fitting prescriptions. The randomised trial revealed differences in aided audibility at low input level between prescription groups, but no significant differences in speech and language abilities.

Parental Decision-Making and Deaf Children: A Systematic Literature Review.

Parents or caregivers of children who are deaf or hard of hearing are required to make complex and rational decisions soon after the confirmation of hearing loss. Ways of facilitating decision-making have been a focus within the healthcare sector for two decades and shared decision-making is now widely viewed as the standard for good clinical care. A systematic literature review was undertaken to identify the extent to which the principles of shared decision-making and informed choice have been implemented for parents when they make decisions related to their children with permanent hearing loss. Five databases were searched for peer-reviewed papers describing the results of original research published from 2000 to 2017, yielding 37 relevant papers. Studies were reviewed using the three phases of decision-making-information exchange, deliberation, and implementation. Two decisions dominated these studies-implantable devices and communication modality. Most papers dealt with decision-making in the context of bilateral hearing loss, with only one study focusing on unilateral hearing loss. The review identified gaps where further research is needed to ensure the lessons learnt in the broader decision-making literature are implemented when parents make decisions regarding their child who is deaf or hard of hearing.

Factors Influencing Caregiver Decision Making to Change the Communication Method of their Child with Hearing Loss.

The communication journey of a child with hearing loss is often a complex, interwoven process in which the child's use of language or method of communication may change numerous times. As there has been limited research exploring the caregiver decision making process behind making such changes, this qualitative descriptive study aimed to explore the factors which influence the caregiver decision making process to change the communication method of their child with hearing loss. Individual semi-structured in-depth interviews were conducted with seven caregivers of children with hearing loss in Australia. Thematic analysis revealed five key themes which influenced caregiver decisions regarding changes to their child's method of communication, including: (1) family characteristics; (2) family access to information; (3) family strengths; (4) family beliefs; and (5) family-centered practice. The overall finding that the family unit is at the core of decision-making has important clinical implications regarding early intervention professionals' provision of family-centered services when working with the families of children with hearing loss.

Developing Sound Skills for Reading: Teaching Phonological Awareness to Preschoolers With Hearing Loss.

This study evaluated the effectiveness of intervention for developing deaf and hard-of-hearing (DHH) preschoolers' phonological awareness (PA) skills. Thirty children (mean age 57 months) with aided, bilateral hearing loss (and who primarily communicated using spoken English) were recruited in the year prior to commencing formal schooling. The study used an experimental design with participants assigned to one of two intervention conditions-vocabulary instruction, or explicit PA instruction. Both intervention programs were based around items drawn from a common word set and presented over six short weekly sessions by a researcher using a computer tablet. Overall, participants showed greater knowledge of word items used in interventions and improved performance on rhyme-based PA skills following intervention. However, the PA group showed significantly greater improvement than the vocabulary group for both overall PA performance and for consonant-vowel-consonant blending. DHH children's order of PA skill development was also examined, with comparison to that shown for children without hearing loss. The results provide early encouraging evidence about the potential benefit of explicit PA instruction for this population.

Hearing aid and cochlear implant use in children with hearing loss at three years of age: Predictors of use and predictors of changes in use.

OBJECTIVE: To examine usage patterns of hearing aids and cochlear implants in children up to three years of age, how usage changes longitudinally, and factors associated with device usage. DESIGN: Parent report and Parent's Evaluation of Aural/oral Performance of Children (PEACH) data were obtained at six and twelve months after hearing-aid fitting or cochlear implant switch-on, and again at three years of age. The effect of device use on auditory functional performance was investigated using the PEACH questionnaire. STUDY SAMPLE: Four hundred and thirteen participants from the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study were included for analysis. RESULTS: For users of hearing aids, higher usage at three years was associated with higher maternal education, and more severe hearing loss. For users of cochlear implants, higher usage was associated with higher maternal education and the absence of additional disabilities. Higher PEACH scores were associated with higher usage scores. After allowing for the effects of demographic characteristics, device use was not a significant predictor of functional performance. CONCLUSIONS: Sixty-two percent of children achieved consistent use (> 75% of waking hours) within the first year of receiving a hearing aid or a cochlear implant, and 71% by three years of age.

The audiological journey and early outcomes of twelve infants with auditory neuropathy spectrum disorder from birth to two years of age.

OBJECTIVE: To describe the audiological journey of a group of infants with auditory neuropathy spectrum disorder (ANSD) following the fitting of hearing aids, and to investigate the potential benefits of including cortical auditory-evoked potentials (CAEPs) and a measure of functional auditory behaviour during early audiological management. DESIGN: Results from chart revision of estimated hearing threshold, early behavioural testing, parental observation, and functional auditory behaviour assessments were described, and compared to visual reinforcement audiometry (VRA) thresholds obtained at a mean corrected age of 10 months (SD 3). The relationship with CAEPs and functional performance was examined. STUDY SAMPLE: The study included 12 infants diagnosed with ANSD and fitted with amplification. RESULTS: The estimated 4FA at a mean corrected age of four months (SD5) was within ± 10 dB of VRA results in 75% of infants when unaided and aided behavioural observation audiometry (BOA), together with unaided and aided parental observations was combined. Infants with a greater proportion of CAEPs present had higher PEACH scores. CONCLUSIONS: Delaying amplification until VRA results were available would have led to a significant period of auditory deprivation for infants in this study group. None of the assessments could accurately determine hearing thresholds when used in isolation, however when used in combination clinicians were able to obtain sufficient information to fit hearing aids early, and identify infants requiring closer monitoring.

Factors Affecting Psychosocial and Motor Development in 3-Year-Old Children Who Are Deaf or Hard of Hearing.

Previous research has shown an association between children's development of psychosocial and motor skills. This study evaluated the development of these skills in 301 three-year-old deaf and hard of hearing children (M: 37.8 months) and considered a range of possible predictors including gender, birth weight, age at first fitting with hearing devices, hearing device used, presence of additional disabilities, severity of hearing loss, maternal education, socio-economic status (SES), language ability, and communication mode. Caregivers reported on children's development using the Child Development Inventory (CDI). On average, both psychosocial and motor development quotients were within the typical range for hearing children, with large individual differences. There was a positive correlation between language ability and both social and motor development, and also between social and motor development. Age at first fitting of hearing aids (as an indicator of age at identification of hearing loss), SES, degree of hearing loss, and maternal education were not significant predictors of social skill or motor development, whereas presence of additional disabilities and birth weight were. Girls performed better than boys on all but the Gross Motor subscale of the CDI. Children with hearing aids tended to perform better than those with cochlear implants on the Gross Motor subscale.