High General Health Literacy Does Not Ensure Hearing Loss Health Literacy in Mothers of Children Who Are Deaf and Hard of Hearing.

PURPOSE: The purpose of this study was to characterize general health literacy and hearing loss health literacy for mothers of children who are deaf and hard of hearing (DHH). METHOD: Participants included 25 mothers of 2-year-old and 3-year-old children who had a diagnosis of permanent, bilateral hearing loss for at least 1 year. Measures of general health literacy and hearing loss health literacy were collected. RESULTS: Results indicated that mothers had high general health literacy but had lower hearing loss health literacy skills than expected. Although mothers had high education and experience of at least 1 year of having a child with hearing loss, performance on hearing loss health literacy measures was low. CONCLUSION: Caregiver understanding of hearing loss terminology and concepts is essential for decision making regarding their child's hearing loss health care.

An Analysis of Mental State Verb and Complex Syntax Use in Children Who Are Deaf and Hard of Hearing.

PURPOSE: Children who are deaf and hard of hearing (DHH) have documented deficits with complex syntax and vocabulary knowledge. Mental state verbs (MSVs) are necessary for some kinds of complex syntax use and communicate abstract concepts needed for academic language. The purpose of this study was to examine the frequency, diversity, and syntactic context of MSV use in children who are DHH compared to children with typical hearing (CTH). METHOD: Seventy-three preschool children (23 with cochlear implants, 22 with hearing aids, and 28 with typical hearing) completed a structured language sample as part of a larger assessment battery. Samples were analyzed and compared across groups for use of MSVs, diversity in MSV use, and syntactical context for MSVs. RESULTS: Children who are DHH used significantly fewer MSV in complex syntax, a smaller diversity of MSV, and significantly fewer MSV in obligatory contexts compared to CTH. Results for the cochlear implants and hearing aid groups were not significantly different from one another despite differing levels of hearing loss. CONCLUSION: Children who are DHH demonstrate significant differences in the rate, diversity, and complexity of MSV use compared to peers with typical hearing. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24091860.

Lexical-Semantic Organization as Measured by Repeated Word Association in Children Who Are Deaf and Hard of Hearing Who Use Spoken Language.

PURPOSE: This study compares responses of children who are deaf and hard of hearing (DHH) who use spoken language with responses of children who have typical hearing on a repeated word association task to evaluate lexical-semantic organization. METHOD: This study included 109 participants in early kindergarten or who had completed first grade. The younger group included 30 children with typical hearing, 22 with hearing aids, and 21 with cochlear implants. The older group included 16 children with typical hearing, nine with hearing aids, and 11 with cochlear implants. Children were asked to give a word associated with 24 stimuli words. Responses were coded according to their relation to the target. RESULTS: An analysis of variance revealed that older children, regardless of hearing status, produced more semantically related responses to prompts than younger children. Children in the younger DHH group differed from children with typical hearing in their production of non-semantically related responses: They produced errored responses at higher rates. CONCLUSION: This preliminary data may indicate an early deficit in recognition of semantic relations between words for children who are DHH and provides a basis for continued longitudinal study of changes in lexical-semantic organization.

The Contribution of Phonological Processing to Reading and Spelling in Students With Cochlear Implants.

PURPOSE: Children with cochlear implants (CIs) have difficulty with literacy, and although it is established that phonological processing underlies literacy skills in children with typical hearing (TH), the relation of phonological processing and literacy in children with CIs is not fully understood. This study evaluated the contributions of phonological processing to word-level reading and spelling skills of children with CIs. METHOD: Thirty children with CIs and 31 children with TH in Grades 3 through 6 completed measures of word reading, spelling, and phonological processing. The contributions of phonological processing (phonological awareness, phonological memory, and phonological recoding) to reading and spelling were evaluated. RESULTS: Children with CIs scored lower across measures of reading, spelling, phonological awareness, and phonological memory, but not phonological recoding, than children with TH. Phonological processing components were significant predictors of reading and spelling for children with CIs but not for children with TH. CONCLUSIONS: This study underscores the important contribution of phonological processing, particularly phonological awareness and phonological memory, in literacy development for children who use CIs. These results suggest an urgent need for research into not only the underlying mechanisms that predict literacy outcomes but also evidence-based interventions to support these students' literacy.

A Longitudinal Investigation of Code-Related Emergent Literacy Skills in Children Who Are Deaf and Hard of Hearing Across the Preschool Years.

PURPOSE: The purpose of this longitudinal investigation was to compare the developmental trajectories of code-related emergent literacy skills of children who are deaf and hard of hearing (DHH) who use amplification and spoken language across the preschool years. METHOD: Thirty children who are DHH and 31 children with typical hearing completed a language and emergent literacy assessment at 6-month intervals from age 4 through 6 years. Growth curve analysis was used to compare developmental trajectories between groups of the code-related skills of phonological awareness, phonological memory, phonological recoding, alphabet knowledge, and conceptual print knowledge. RESULTS: Growth across the preschool years was observed on all code-related emergent literacy skills across groups. Children who are DHH scored consistently lower than children with typical hearing on phonological awareness, phonological memory, and conceptual print knowledge; no group differences were observed for phonological recoding or alphabet knowledge. No interactions of time and group were significant. CONCLUSIONS: Children who are DHH exhibit consistent deficits in phonological awareness, phonological memory, and conceptual print knowledge across the preschool years and begin formal literacy instruction with a weaker foundation in emergent literacy skills. Future work should focus on optimizing emergent literacy interventions for children who are DHH during the preschool years. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21998153.

Impact of Meeting Early Hearing Detection and Intervention Benchmarks on Spoken Language.

This study compared preschool spoken language outcomes for children with hearing loss who met Early Hearing Detection and Intervention (EHDI) guidelines to those who did not, as well as to compare outcomes for those who met current EHDI guidelines to those who met earlier benchmarks. Finally, the predictive role of meeting each component of the guidelines was evaluated relative to language outcomes. Children who met the EHDI guidelines had higher language scores than those who did not; however, there was no difference between children who met the current guidelines and those who met the earlier benchmarks. Entering early intervention by six months of age was the only unique predictor of spoken language outcomes. The findings suggest that EHDI programs should target increasing the number of children with hearing loss who meet the current 1-3-6 benchmarks with a particular focus on enrollment in early intervention by six months.

Impact of FM System Use on Acquisition of Phonological Awareness Skills for Children at Risk of Dyslexia: A Preliminary Classroom Study.

PURPOSE: This study evaluated the effects of utilizing a frequency modulation (FM) system during phonological awareness intervention for students at risk for dyslexia in a classroom setting. METHOD: Four first-grade students participated in an adapted-alternating single-case design study. Participants completed intervention targeting two phonological awareness skills and were assigned to wear an FM system during lessons targeting one skill and no FM system during lessons targeting the second skill. Performance was assessed using daily assessments on the skills targeted during intervention and one additional skill. RESULTS: Two participants demonstrated quicker and more pronounced improvement on the skill learned while wearing the FM system. The other two participants did not show improvement on any skill. CONCLUSIONS: For children who made gains as a result of phonological awareness intervention, the FM system was associated with quicker and greater improvement. FM systems show promise as a tool to use during phonological awareness training for at least some children at risk for dyslexia. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.20540139.

The Effects of Virtual Assessment on Capturing Skill Growth in Children With Hearing Loss.

PURPOSE: The purpose of this study is to evaluate the effects of switching from in-person assessment to virtual assessment during the COVID-19 pandemic on the growth trajectories of children with hearing loss who are learning spoken language. METHOD: Sixty-eight children with typical hearing, 44 children with cochlear implants, and 47 children with hearing aids were assessed with a norm-referenced measure of receptive vocabulary, a criterion-referenced measure of phonological awareness, and a criterion-referenced measure of conceptual print knowledge at least 4 times, at 6-month intervals, between the ages of 4 and 6 years. Of those participants, 26 children with typical hearing, 13 children with cochlear implants, and 13 children with hearing aids entered virtual testing as a result of the COVID-19 pandemic. The slopes of growth for children who entered virtual testing were compared to their own slopes prepandemic and to the growth slopes of children who completed all testing in-person, prepandemic. RESULTS: Within-subject comparisons across all measures did not show a change in growth slopes prepandemic to postpandemic. For the measure of conceptual print knowledge, children who were tested during the pandemic showed slower overall growth than children who were tested prepandemic. No effects of hearing status were found across growth on any measure. CONCLUSION: These preliminary data support the use of virtual assessment to measure growth in receptive vocabulary, phonological awareness, and conceptual print knowledge in children with hearing loss learning spoken language.

Oral Language Acquisition in Preschool Children Who are Deaf and Hard-of-Hearing.

The purpose of this study was to compare developmental trajectories of oral language acquisition of children who are deaf and hard of hearing (DHH) and children with typical hearing across the preschool years. Thirty children who are DHH who use amplification and spoken language and 31 children with typical hearing completed an early language and literacy assessment battery every six months from age 4 to age 6. The developmental trajectories of each group's language skills were examined via growth curve analysis. Oral language skills were lower for children who are DHH than for children with typical hearing at study entry. For vocabulary, children who are DHH demonstrated growth over the two years but did not close the gap in performance over time. For morphosyntax, specifically verb tense marking, children who are DHH demonstrated growth over preschool, becoming more adult-like in their productions.

Location Effects on Spoken Language and Literacy for Children who are DHH.

The purpose of this study was to consider how living in an area that qualifies for a rural health grant interacts with a child's hearing status to affect early language and literacy development. Four-year-old children with hearing aids (n = 45), cochlear implants (n = 47), and with typical hearing (n = 66) completed measures of spoken language knowledge and of emergent literacy skills as part of a larger longitudinal investigation. A significant interaction effect between location (rural or urban/suburban) and amplification group was detected for letter knowledge: children with hearing aids exhibit a performance that is particularly affected by rural location. Overall, children with cochlear implants performed lower across all measures than children with typical hearing, and children with hearing aids performed lower than children with typical hearing on measures of phonological awareness, vocabulary, omnibus language knowledge and articulation.

Transitioning Speech-Language Assessment to a Virtual Environment: Lessons Learned From the ELLA Study.

Purpose The COVID-19 pandemic has necessitated a quick shift to virtual speech-language services; however, only a small percentage of speech-language pathologists (SLPs) had previously engaged in telepractice. The purpose of this clinical tutorial is (a) to describe how the Early Language and Literacy Acquisition in Children with Hearing Loss study, a longitudinal study involving speech-language assessment with children with and without hearing loss, transitioned from in-person to virtual assessment and (b) to provide tips for optimizing virtual assessment procedures. Method We provide an overview of our decision making during the transition to virtual assessment. Additionally, we report on a pilot study that calculated test-retest reliability from in-person to virtual assessment for a subset of our preschool-age participants. Results Our pilot study revealed that most speech-language measures had high or adequate test-retest reliability when administered in a virtual environment. When low reliability occurred, generally the measures were timed. Conclusions Speech-language assessment can be conducted successfully in a virtual environment for preschool children with hearing loss. We provide suggestions for clinicians to consider when preparing for virtual assessment sessions. Supplemental Material https://doi.org/10.23641/asha.14787834.

Linguistic Predictors of Single-Word Spelling in First Grade Students with Speech and/or Language Impairments.

The purpose of this study was (a) to compare the single-word spelling performance of first graders across four groups that varied by speech and language status; and (b) to determine the linguistic predictors of first-grade spelling for children with speech and/or language impairment compared to children with typical development. First grade children (N = 529) completed measures of spelling, early word reading, expressive vocabulary, phonological awareness, and morphosyntactic knowledge. Children with language impairment, with or without speech impairments, demonstrated lower spelling performance than children with typical development; children with speech impairment only did not differ from children with typical development. Additionally, early word reading and phonological awareness predicted spelling performance, regardless of group. Study findings indicate that language status, but not speech status, is a risk factor for low spelling performance in first grade, and that first grade spelling instruction should focus on developing early word reading and phonological awareness.

The Production of Complex Syntax in Spontaneous Language by 4-Year-Old Children With Hearing Loss.

Purpose Proficiency with complex syntax is important for language and reading comprehension, and production of complex syntax begins to emerge shortly after a young child begins using two-word combinations. Complex syntax production in preschool children with hearing loss who use spoken language has been explored minimally. The purpose of this study was to compare complex syntax production of 4-year-old children with hearing loss to age-matched and language-matched peers with normal hearing. Method Seventy-two children completed a language assessment battery, including a structured language sample. Complex syntax density and number and accuracy of productions of particular types of complex syntax were compared across three groups: 4-year-old children with hearing loss, an age-matched group of children with normal hearing, and an mean length of utterance (MLU)-matched group of children with normal hearing. Results Children with hearing loss had lower complex syntax density and fewer correct productions of coordinated clauses, subordinate clauses, and simple infinitives than their age-matched, but not language-matched, peers. Furthermore, children with hearing loss had lower accuracy than the age-matched group on simple infinitives and lower accuracy than both the age- and MLU-matched groups on full propositional complements and subject relative clauses. Conclusion Children with hearing loss exhibit delays in complex syntax acquisition as compared to their same-age peers and disruptions in development on some complex structures as compared to MLU-matched, younger children. Supplemental Material https://doi.org/10.23641/asha.14080193.

An Exploration of Early Spelling in Kindergarten Children With Hearing Loss.

Purpose The purpose of this study was to determine if group differences exist in spelling accuracy or spelling errors between kindergarten children with hearing loss and children with normal hearing loss. Method Participants included 23 kindergarten children with hearing loss and 21 children with normal hearing. All children used spoken English as their primary language, and the children with hearing loss used amplification. Participants completed three single-word spelling assessments, a language assessment, and an oral reading assessment. Spelling was scored holistically and with two linguistic-based scoring systems. Results Children with hearing loss did not differ significantly from children with normal hearing in spelling accuracy or linguistic-based spelling error analyses. Conclusions The current study provides evidence that children with hearing loss in kindergarten do not differ significantly in their spelling errors compared to children with normal hearing, aside from a lower proportion of mental graphemic representation errors. With these data, in combination with previous research conducted, speech-language pathologists can further individualize treatment to focus on these specific error patterns. Additionally, this focus of treatment can help better prepare children with hearing loss for spelling and writing tasks in later grades. Future research should be conducted to determine when in elementary school the differences in spelling errors are initially seen.

Nonverbal Intelligence Predicts Performance of Preschool Children With Hearing Loss on Norm-Referenced Language Measures But Not Language Sample Analysis.

OBJECTIVES: The purpose of this study was to explore the effects of nonverbal intelligence on spoken language performance in children with hearing loss who use amplification and spoken language. Specifically, we compared language performance measured by norm-referenced measures compared with spontaneous language sample measures. DESIGN: Nonverbal intelligence and spoken language skills were analyzed using norm-referenced nonverbal intelligence and language assessments and language sample analyses in 92 children ages 3 to 6 who varied by hearing and nonverbal intelligence status. All children had nonverbal intelligence within the average or above-average range. RESULTS: Regression analyses revealed that, after controlling for maternal education and hearing status, nonverbal intelligence contributed unique variance to norm-referenced language measures but not spontaneous language measures. CONCLUSIONS: Performance on norm-referenced language measures is influenced by nonverbal intelligence, whereas functional language use measured by spontaneous language samples is not. These findings suggest that spontaneous language measures may contribute additional value to language assessment batteries that are independent of nonverbal intelligence.

The Relation Between Linguistic Awareness Skills and Spelling in Adults: A Comparison Among Scoring Procedures.

Purpose Spelling is a skill that relies on an individual's linguistic awareness, the ability to overtly manipulate language. The ability to accurately spell is important for academic and career success into adulthood. The spelling skills of adults have received some attention in the literature, but there is limited information regarding which approach for analyzing adults' spelling is optimal for guiding instruction or intervention for those who struggle. Thus, we aimed to examine the concurrent validity of four different scoring methods for measuring adults' spellings (a dichotomous scoring method and three continuous methods) and to determine whether adults' linguistic awareness skills differentially predict spelling outcomes based on the scoring method employed. Method Sixty undergraduate college students who were determined to be average readers as measured by a word reading and contextual word reading task were administered a spelling task as well as morphological, orthographic, phonemic, and syntactic awareness tasks. Results All four scoring methods were highly correlated suggesting high concurrent validity among the measures. Two linguistic awareness skills, morphological awareness and syntactic awareness, predicted spelling performance on both the dichotomous and continuous scoring methods. Contrastively, phonemic awareness and orthographic awareness predicted spelling performance only when spelling was scored using a continuous measure error analysis. Conclusions The results of this study confirm that multiple linguistic awareness skills are important for spelling in adults who are average readers. The results also highlight the need for using continuous measures of spelling when planning intervention or instruction, particularly in the areas of orthographic and phonemic awareness.

Teaching Vocabulary to Improve Print Knowledge in Preschool Children with Hearing Loss.

PURPOSE: The purpose of this article was to examine evidence that (a) published measures may tap different categories of print knowledge and result in disparate findings in the literature, (b) concept vocabulary knowledge in children with hearing loss may exacerbate deficits in conceptual print knowledge, and (c) concept vocabulary can be taught via direct instruction for preschool children with hearing loss. METHOD: In Study 1, an item analysis of published print knowledge measures was performed to determine the prevalence of concept vocabulary in test items. Additionally, the performance on a conceptual print knowledge measure was compared for preschool children with and without hearing loss. In Study 2, four preschool children participated in a multiple probe across behaviors treatment design to determine if concept vocabulary could be explicitly taught to children with hearing loss. RESULTS: Differences emerged in use of concept vocabulary on test items across the measures, which may explain disparate findings that have been reported in this area. Additionally, children with hearing loss performed lower than children with typical hearing on items that contained concept vocabulary but not on items that did not. Finally, we found initial evidence that direct instruction can improve concept vocabulary for children with hearing loss, and it might not be necessary to separately target each concept category. CONCLUSION: This series of studies lays groundwork for future research confirming a connection between conceptual print knowledge and conceptual vocabulary knowledge, and offers evidence for intervention that could be used clinically to teach conceptual vocabulary.

Home Literacy Environment and Emergent Skills in Preschool Children With Hearing Loss.

Home literacy practices reported by parents of preschool children with hearing loss were compared to those reported by parents of their peers with typical hearing. Parents completed a questionnaire from Boudreau, D. (2005. Use of a parent questionnaire in emergent and early literacy assessment of preschool children. Language, Speech, and Hearing Services in Schools, 36, 33-47. doi:10.1044/0161-1461(2005/004)) assessing home literacy practices across areas such as parent facilitation of literacy and time spent reading per week. As part of a larger study, children completed language and emergent literacy assessments. Parents of both groups reported similar amounts of time spent reading to their children and scored similarly on report of parent facilitation of literacy, even though children with hearing loss scored lower on measures of emergent literacy. However, parents of children with typical hearing reported that their children had higher engagement and interest in books than children with hearing loss. Additionally, only child engagement with books was correlated with emergent literacy skills and only for children with hearing loss. The results suggest that parent facilitation of literacy alone is not correlated with emergent literacy scores; children must take an active role in their reading development. Children with hearing loss must be active participants during shared book reading. It is therefore essential to develop ways to actively engage children with hearing loss during reading activities.

Toward Understanding the Lexical-Morphological Networks of Children With Specific Language Impairment: Analysis of Responses on a Morphological Production Task.

Purpose The purpose of this study was to characterize the lexical-morphological networks of children with specific language impairment (SLI) compared to children with typical language by analyzing responses on a morphological derived form production task. Method School-age children with SLI (n = 32) and peers with typical language (n = 40) completed an oral cloze derived form production task (Carlisle, 2000). On this task, children were expected to complete verbally presented sentences with a derived form of a provided morphological stem. Responses were coded as correct or incorrect following Carlisle's (2000) stated correct responses. Incorrect responses were coded as scorable or unscorable, and then scorable responses were coded as pseudowords or real words. Real words were further coded according to whether they were repetitions of the given stem. Results There was a statistically significant between-group difference for mean correct responses (d = 1.43). The scorable incorrect responses of children with SLI included a lower mean proportion of pseudowords than did the incorrect responses of children with typical language (d = 0.76). Conclusion Because children with SLI produced a lower proportion of pseudowords as scorable incorrect responses than peers with typical language, we conclude that they have less developed lexical-morphological networks and, thus, less derivational morphology knowledge than peers with typical language.

Linguistic Contributions to Word-Level Spelling Accuracy in Elementary School Children With and Without Specific Language Impairment.

Purpose Children with specific language impairment (SLI) are more likely than children with typical language (TL) to exhibit difficulties in word-level spelling accuracy. More research is needed to elucidate the contribution of linguistic knowledge to word-level spelling accuracy in this population. The purpose of this study was to explore the contributions of linguistic knowledge to spelling accuracy in a group of 2nd- to 4th-grade children with SLI and a group of 2nd- to 4th-grade children with TL. Method Participants were 32 children with SLI and 32 children with TL in Grades 2 through 4. Five areas of linguistic knowledge were assessed: phonological awareness, morphological knowledge, orthographic pattern knowledge, mental grapheme representation knowledge, and vocabulary knowledge. Mixed-effects logistic regression models were utilized to address the research aim. Results Mental grapheme representation knowledge was selected as a significant predictor in both models; however, phonological awareness was the only additional significant predictor in the model for children with SLI, whereas morphological knowledge was the only other significant predictor in the model for children with TL. Orthographic pattern knowledge and vocabulary knowledge were not significant for either group. Conclusions The results suggest that spelling instruction and intervention for children with SLI should take linguistic knowledge into account and explicitly relate linguistic knowledge to spelling. Additionally, future research should consider if instructional targets for children with SLI should differ from targets for children with TL and if these findings represent a delay or a disorder in spelling acquisition for children with SLI.