Original Article

Functional Communication of Children Who Are Deaf or Hard-of-Hearing Jareen Meinzen-Derr, PhD,*† Susan Wiley, MD,†‡ Sandra Grether, PhD,‡ Jannel Phillips, PhD,‡ Daniel Choo, MD,† Julie Hibner, MA,‡ Holly Barnard, PhD‡ ABSTRACT: Objective: The primary aim of this study was to investigate the relationship between language levels and communication and social function skills in young children who are deaf/hard-of-hearing. Method: A cross-sectional design was used with participants sampled predominately from a single clinic setting. Children between 3 and 6 years of age with permanent bilateral hearing loss were enrolled in the study. All children received the Preschool Language Scales—Fifth Edition language assessment and a neurocognitive assessment using the Leiter International Performance Scale—Revised at the study visit. Communication and social function skills were measured using the Vineland Adaptive Behavior Scales—Second Edition (VABS-II; mean 100 6 15) and the Pediatric Evaluation of Disability Inventory (PEDI; mean 50 6 10). Results: Analysis included 65 children with mild to profound bilateral hearing loss (mean age 56.8 months, SD 6 14.1); 52% had hearing loss in the mild to moderate range. The mean nonverbal intelligence quotient (IQ) was 95.7 (618.8), the mean receptive language standard score was 83.7 (618.6), and mean expressive language standard score was 83.0 (618.5). The mean VABS-II communication standard score was 89.1 (617.5), and the mean PEDI social function score was 39.6 (615.3). Both nonverbal IQ and receptive language relative to nonverbal IQ (the ratio of language to IQ) were significantly associated with communication and social functioning, explaining more than 50% of the variance in communication function scores. Children with language commensurate with their IQ had significantly higher communication and social function scores than children with language significantly lower than IQ. This finding was consistent across different levels of IQ and independent of degree of hearing loss. Conclusion: Even with early identification and intervention, hearing loss continues to have a life-long impact on functioning. It is important to identify when language levels are not meeting a child’s capabilities in order to intervene most effectively. (J Dev Behav Pediatr 35:197–206, 2014) Index terms: deafness, hard-of-hearing, functional outcomes, communication.

H

earing loss is one of the most common developmental conditions seen during infancy, with 2 to 3 per 1000 infants born each year in the United States having permanent bilateral hearing loss.1–4 By school age, more than 40,000 children per year have significant hearing loss that could affect their development. Because the majority of children with hearing loss are born to hearing parents,5 many caregivers have relatively little From the *Division of Biostatistics and Epidemiology, †Division of Otolaryngology, ‡Division of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH. Received September 2013; accepted January 2014. This investigation was supported by Grant R40MC21513 from the Maternal and Child Health Research Program, Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, and Department of Health and Human Services. Disclosure: The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jdbp.org). Address for reprints: Jareen Meinzen-Derr, PhD, Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue ML 5041, Cincinnati, OH 45229; e-mail: [email protected]. Copyright Ó 2014 Lippincott Williams & Wilkins

Vol. 35, No. 3, April 2014

understanding of the impact of hearing loss on development. Even with the advances of early identification and intervention, hearing loss continues to have a life-long impact on independent functioning. Hearing loss identification through newborn hearing screening and subsequent early intervention is vital to improved language development for children who are deaf or hard-of-hearing.6–11 Research on language development among children with hearing loss has exploded with the wide implementation of Universal Newborn Hearing Screening and pediatric cochlear implantation. Studies have shown that early identification11–13 of and subsequent intervention7–9,14–16 for hearing loss have positive effects on language and vocabulary development. Because language skills in children should be appropriate for their developmental (or cognitive) level,17–19 this research supports the notion that children with hearing loss have the potential of achieving “appropriate” language levels. Unfortunately, the observed early benefits of intervention on language are not always maintained into the later years.20 Many children who are deaf/hard-of-hearing continue to fall short of achieving age-appropriate language levels, often functioning in the low average range when compared to www.jdbp.org | 197

hearing children.8,21–23 Moreover, relatively large numbers of children with hearing loss struggle with significantly lower language levels disproportionate to their potential based on nonverbal cognitive assessments.24,25 These lags in early language often worsen rather than improve with age, irrespective of hearing loss severity.26,27 Despite comprehensive efforts of screening and identifying children with hearing loss early and emphasis on intervention, language continues to lag behind their capabilities.23 A motivation for a solid language and communication foundation is to promote independent functioning. Functional assessments take a whole child approach to understanding day-to-day needs for effectively integrating into the community, which is a high priority in early intervention and developmental research,28–30 and a critical factor to consider when assessing a child’s strengths and weaknesses.30 Functional skills are defined as a child’s ability to perform essential daily tasks in the areas of self-care (eating, dressing, bathing), mobility (changing positions, movement in space at home and community), and social cognition or social function (communicating basic needs, problem solving, social interaction with peers).31 Unfortunately, research regarding global functional abilities of children who are deaf or hard-of-hearing is extremely limited. For instance, the terms functional performance or functional skills have been commonly used to describe functional hearing in children who are deaf/hard-of-hearing. While the literature provides evidence to support language acquisition for children who are deaf/hard-of-hearing, the practical benefits of language, such as functional communication or other functional abilities, have not been well described. The objective of this study was to investigate how language levels, independent of cognitive abilities, impact independent social functional skills in young children who are deaf/hard-of-hearing. Our preliminary work in children with cochlear implants suggests that a gap between language abilities and nonverbal intelligence quotient plays a significant role in the area of social functioning.32,33

METHODS Participants Sixty-five children with mild to profound bilateral hearing loss, age 3 to 6 years (mean age 56.8 6 14.7 months) were enrolled in a cross-sectional study of language and functional outcomes between March 2011 and July 2013. Most participants were recruited from a single pediatric tertiary care center with a strong multidisciplinary approach to the care of children who are deaf/hard-of-hearing. This program also houses an active cochlear implant program. Details regarding the clinical evaluation of children who are deaf/hard-ofhearing are reported elsewhere.34 Parents of eligible study participants were contacted by letter, which 198 Functional Communication and Language Levels

briefly described the study, and a follow-up phone call. Parents could also actively contact study personnel through information listed on advertisements posted through the medical center. A few participants (n 5 6) were also recruited from a second site using the same strategy of letters with a follow-up phone call. Written informed consent was obtained at the study visit. Children who were unable to complete testing (i.e., intelligence quotient [IQ] , 40; severe motor deficits) and children who had a syndrome or disorder that specifically affected language (e.g., autism spectrum disorder) were excluded from the overall study. Children whose hearing loss was identified after 36 months of age were also excluded. All children received a language assessment and a neurocognitive assessment at the study visit. Parents filled out a questionnaire that collected information regarding demographics, schooling, and children’s current therapy attendance. Table 1 summarizes demographic and socioeconomic characteristics of the study population. The etiology of hearing loss was unknown for nearly 40% of children and was due to inner ear anomalies in 15%. More than half of the study participants used a cochlear implant. All parents had hearing and used oral communication as the primary communication modality in the home. The majority of parents reported having at least a college degree. Almost one third of the children utilized public insurance. Forty percent of families reported total household income to be below $50,000 a year, with 15% living at or below the poverty level.

Audiometry Audiograms, which contained objective information about degree of hearing loss and level of aidable hearing (audibility), were obtained from medical/audiologic charts. For the purpose of this study, severity of hearing loss was classified using a 4-frequency pure tone average (in the better hearing ear) and defined as follows: mild (26–40 dB loss), moderate (41–55 dB loss), moderately severe (56–70 dB loss), severe (71–90 dB loss), and profound ($91 dB loss). Effectiveness of amplification was determined based on aided thresholds for both hearing aid and cochlear implant recipients and real-ear measures of hearing aid gain and output for hearing aid users. Speech reception/speech awareness thresholds (SRT/SAT), which are measures of an individual’s threshold for hearing speech, were collected from audiograms. Data from audiograms closest to the study visit were used in the analysis.

Assessment Measures Table 2 summarizes the assessment measures reported in this study. Children were administered the Preschool Language Scales—Fifth Edition35,36 by a speech-language pathologist with experience assessing language for children with developmental disabilities along with children who are deaf/hard-of-hearing. For children who used a total communication approach (combination of oral and Journal of Developmental & Behavioral Pediatrics

Table 1. Demographic Characteristics of 65 Children Who Are Deaf or Hard-of-Hearing Characteristics

N or Mean

% or SD

Table 1.

Continued

Characteristics Communication strategies

N or Mean

% or SD

a

Mean age of study (mo)

56.8

14.1

Oral

Male

38

58.5%

Sign

30

46.2%

Race—white

50

76.9%

Behavior

14

21.5%

.1 strategy

32

49.2%

Unknown

25

38.5%

Premature

11

16.9%

Inner anomaly

Etiology of HL

10

15.4%

Syndrome

6

9.2%

Genetic

5

7.7%

Infection (CMV or meningitis)

3

4.6%

Other Mean age of HL identification (mo)

5

7.7%

10.9 (median 6)

10.8

Degree of HL Mild Moderate

9

13.9%

25

38.5%

Severe

14

21.5%

Profound

17

26.1%

Use of cochlear implant

26

Duration of implant use (mo)

31.6

40% 14.8

Use of hearing aid

44

67.7%

Premature at birth

17

26.2%

Maternal education HS/GED Some college

7

10.8%

20

30.7%

College

20

30.7%

Postgraduate

18

27.7%

4

6.2%

Paternal education ,HS HS/GED

16

24.6%

Some college

12

18.5%

College

20

30.8%

Postgraduate

9

13.9%

Unknown

4

6.2%

Private

32

49.2%

Public

18

27.8%

Insurance

Combo

15

23.1%

10

15.4%

0

14

21.5%

1

30

46.2%

2

11

16.9%

3

9

13.9%

4

1

1.5%

Income at poverty level Number of siblings

(Table continues)

Vol. 35, No. 3, April 2014

59

90.8%

add up to .100% due to multiple strategies used by individuals. CMV, cytomegalovirus; HL, hearing loss; HS/GED, high school/general education diploma.

aPercentages

sign language), sign support was used in the scoring and an interpreter was present. No child in the study used sign language only for communication. Neurocognitive assessments were administered by a neuropsychologist with experience in assessing children who are deaf/hardof-hearing. These included the Leiter International Performance Scale—Revised37 and the Differential Abilities Scale—Second Edition.38 The Behavioral Rating Inventory of Executive Function (BRIEF)39,40 and the BRIEF-P (preschool age) parent forms were administered to parents according to age of the child. Higher scores on the BRIEF reflect greater difficulties. Communication and Social Function Measures Two measures were chosen to characterize communication and social function outcomes in this study; the Vineland Adaptive Behavior Scales—Second Edition (VABS-II)41 and the Pediatric Evaluation of Disability Inventory (PEDI).42 The communication domain of the VABS-II consists of 74 statements describing receptive, expressive, and written communication. The social function domain consists of 99 statements describing interpersonal relationships, play and leisure time, and coping skills. The PEDI is a comprehensive standardized measure of essential daily functional activities containing 197 discrete functional skill items in the domains of self-care, mobility, and social function. Each item is rated as either unable (score 5 0) or capable (score 5 1). The social domain consists of 65 items describing the integration of communication, functional comprehension, expression, and skills necessary for participating in community settings.42 The PEDI is widely used in clinical and research settings with children with a variety of developmental disabilities.43,44 This tool has been used in our previous studies of children who are deaf with additional disabilities to help understand the effectiveness of cochlear implants on functional abilities in that population.32,33 We chose 2 measures of functional abilities, as these constructs have not been evaluated in this population of children. Although there is some overlap in what the tools are measuring, they are different enough to provide a slightly different perspective about child functioning. The PEDI uses a similar conceptual model as the revised World Health Organization’s International Classification of Functioning, Disability, and Health.43 The socialization domain © 2014 Lippincott Williams & Wilkins

199

Table 2. Assessment Measures Used in the Study Assessment

Construct(s) Measured

Used for Analysis

Scoring

Preschool Language Scales— Fifth Edition

Subscales for auditory comprehension (receptive language) expressive communication

Receptive and expressive language standard scores

100 6 15

Leiter International Performance Scale— Reviseda

Nonverbal cognitive abilities

Nonverbal cognitive abilities via Brief IQ

100 6 15

Differential Abilities Scale— Second Edition

Verbal and nonverbal cognitive abilities

Nonverbal composite IQ

100 6 15

Behavioral Rating Inventory of Executive Function (BRIEF) and preschool version (BRIEF-P)

Executive function in the domains of: inhibitory control, shifting behavior, emotional control, initiating tasks and ideas, working memory, planning and organizing

Working memory

50 6 10 for each domain and global/composite scoreb

Vineland Adaptive Behavior Scales—Second Editionc

Daily functional activities in socialization, communication (social life), daily living skills (domestic life), motor skills (mobility)

Communication and social function domains

100 6 15 for each domain and adaptive score

Pediatric Evaluation of Disability Inventory

Essential daily functional activities in domains of self-care, mobility, social function

Social function

50 6 10 for each domain

aLeiter Brief IQ used in analysis. Three children did not have Brief IQ, and Differential Abilities Scale II nonverbal composite was reported instead. bHigher scores reflect greater difficulties. Clinically significant problems on the BRIEF were defined one and one-half SDs above the mean (T-scores $ 65) on the composite indices and subscales. cParent/caregiver rating for was used for this study. BRIEF, Behavioral Rating Inventory of Executive Function; IQ, intelligence quotient.

of the VABS focuses on interpersonal skills, play, and coping. The social function domain of the PEDI encompasses a broader sense of social function than the socialization subscale of the VABS and includes communication, problem solving, play, peer and adult interaction, memory, household chores, self-protection, and community safety.

Language Relative to Cognitive Abilities Because the aim of our study was to understand how the coupling of language and cognition impacts communication and social functioning, we calculated the ratio of language standard scores to nonverbal IQ standard scores. This was done for 2 reasons. First, the strong correlation between language and cognitive scores made it difficult to place both in a multivariable regression model to explain communication and social function skills. Second, although we hypothesized that lower language would be associated with lower functional scores, a child with lower cognitive abilities would be expected to have lower language and lower functional scores. Thus, we wanted to describe the language level in the context of the developmental level of the child. The ratio represented language relative to cognitive abilities, with a ratio close to 1 indicating language that was commensurate with cognitive abilities. Children were divided into 2 groups based on this ratio. Children were classified as having low language if the ratio of language to nonverbal cognitive scores fell below 0.80, 200 Functional Communication and Language Levels

whereas children with a ratio $0.80 had language commensurate with cognitive abilities. In our study population, nearly one third of children had a languageto-cognitive ratio of less than 0.80.

Statistical Analysis Data analysis was conducted using SAS version 9.3. Distributions of the data were assessed for normality for parametric analyses. Pearson correlations were used to assess the associations among nonverbal IQ, language, executive function scores, and communication and social function scores. Principle components analysis was used to create an index for socioeconomic status (SES) using the variables maternal education level, income, and insurance status. This index was used in regression analyses to control for potential confounding related to SES. General linear models were constructed to investigate the independent and collective effects of language and cognition on children’s communication and social functioning, measured by the VABS and the PEDI, respectively. The receptive language score was used to understand the effects of language due to the minimal difference between receptive and expressive language scores (mean difference in scores 0.7, p 5 .44). The nonverbal IQ and the ratio of receptive language to nonverbal IQ were entered into the model first. Other factors entered into the model included the executive Journal of Developmental & Behavioral Pediatrics

function measure of working memory, the SES index, level of aidability (meaning how well a child may have access to sound with either a hearing aid or cochlear implant) as measured by aided SRT or SAT, and age of hearing loss identification. The selection order of variables into the model depended on the p-value and the contribution to the R2. Additional factors (such as the level or degree of hearing loss; use of a cochlear implant) were assessed in the model for potential confounding, but did not remain in the model if they were not statistically significant at the p # .1 level and they did not contribute to the model’s coefficient of determination (R2). Goodness-of-fit statistics and model diagnostics were assessed to verify the appropriateness of the model. The final models were presented with the regression coefficients (b), standard errors, p-values, and partial and overall R2.

RESULTS Cognition and Language The mean nonverbal intelligence quotient (IQ) was 95.7 (618.8) (Table 3). Fifty percent of children had a nonverbal IQ greater than 100 while 22% scored below 80. The mean (SD) receptive and expressive language scores on the Preschool Language Scales—Fifth Edition were 83.7 (618.6) and 83.0 (618.5), respectively. The receptive language score was significantly lower than the nonverbal IQ (p , .0001). Eleven children (17%) had elevated Behavioral Rating Inventory of Executive Function (BRIEF) overall executive composite scores (scores . 65) and 16 children (25%) had elevated working memory scores on the BRIEF, indicating more problems with working memory.

Communication and Social Function The communication and social function mean standard scores for the Vineland Adaptive Behavior Scales— Second Edition (VABS-II) and the Pediatric Evaluation of Disability Inventory (PEDI) are illustrated in Table 2. These scores were significantly lower (1-sample t tests p # .001) than the means for the population (100 and 50 for the VABS-II and PEDI, respectively). Ten (16%) children scored .2 SDs below the mean in the communication function domain of the VABS-II while 15 (24%) children scored .2 SDs below the mean on the PEDI social function domain, indicating significant functional difficulties.

Factors Associated with Communication and Social Function The zero-order Pearson correlation coefficients for the communication and social function scales with other covariates are illustrated in a supplementary table accessible online (see Table, Supplemental Digital Content 1, http://links.lww.com/JDBP/A58). Nonverbal IQ was significantly correlated with the VABS-II communication (rho 5 0.59, p , .0001) and social function domains Vol. 35, No. 3, April 2014

(rho 5 0.48, p , .0001) as well as the PEDI Social Function domain (rho 5 0.45, p 5 .0001). Language, both as a standard score and as a ratio to nonverbal IQ, was also significantly correlated to all 3 domains. The socioeconomic status (SES) index was correlated with the VABS-II domains but not the PEDI Social function. General linear regression analysis revealed that nonverbal IQ and language (the ratio of receptive language to nonverbal cognitive IQ) were significantly associated with communication and social functioning (Table 4). In addition, these 2 factors contribute the most to the overall R2 of the models, contributing to more than 50% of the variance in communication function scores and more than 35% of the variance in social function scores (for both VABS-II and PEDI). As receptive language improves (as the gap between the language standard score and the nonverbal IQ standard score narrows), communication and social function improves. Additionally, decreased working memory was associated with decreased social functioning. These findings remained irrespective of having a cochlear implant or how long a child may have had the implant, or degree of hearing loss. These factors were not significant in the models. Aidability (speech reception/awareness thresholds in the aided condition) was only significant in the model for communication functioning. Neither prematurity nor etiology of hearing loss was significant in any of the models (p . .2 for all models).

Low Language Levels Versus Commensurate Language Levels Linear models were used to determine the adjusted mean communication and social function scores (reported using the least squares means) by commensurate and low language levels, as defined earlier. Scores were adjusted for the same factors in the previous models (nonverbal IQ, working memory, SES). For this purpose, nonverbal IQ was categorized as .100, 80 to 100, and ,80 to better understand the relationship between language and outcome at each of these IQ categories (representing high-average, low-average, and low, respectively). Children in the commensurate language group had significantly higher communication and social function scores than children in the low language group (Figs. 1–3). This finding was consistent across different nonverbal IQ categories and remained unchanged after excluding 4 children who were not primarily oral communicators. Factors such as age, degree of hearing loss, level of aidability, and being a cochlear implant user were not significant in the model.

DISCUSSION In our study, language performance relative to nonverbal cognitive performance was significantly associated with communication and social functioning. Low © 2014 Lippincott Williams & Wilkins

201

Table 3. Performance Profile of 65 Children Who Are Deaf or Hard-ofHearing Assessment Measure

Mean

SD

Nonverbal IQ

95.7

18.8

Working memory

56.9

12.5

Global composite

53.0

12.5

Receptive

83.7

18.6

Expressive

83.0

18.5

86.5

19.6

89.1

17.5

VABS-II social function

90.7

12.9

PEDI social function

39.6b

15.3

Executive function

Language

Language:IQ ratioa Communication and social VABS-II communication

aReceptive

bWhen

language used for the ratio. transformed into standard score of mean 5 100, SD 5 15, the value sample mean is 84.5 with SD of 23.0. IQ, intelligence quotient; PEDI, Pediatric Evaluation of Disability Inventory; VABS-II, Vineland Adaptive Behavior Scales—Second Edition.

language performance relative to nonverbal intelligence quotient (IQ) had a negative functional impact on social skills among children who were deaf/hard-of-hearing. The degree of this functional impact on social skills was often in the range of significant delays, such that children with average or high average cognitive skills who had a gap in language functioning performed similar to children with a mild intellectual disability. These results are concerning as they speak to the significant functional

impact of low language which occurred among the broad range of IQ levels. In fact, language abilities do not have to be outside the range of normal to cause a functional impact. Language levels have been shown to be related to communication and social functioning in studies of language impairment and autism spectrum disorders. Shevell et al45 reported that children with developmental language impairment had persistent difficulties in communication and social function skills by school age. Liss et al46 reported that receptive language was strongly predictive of communication skills (measured on the Vineland Adaptive Behavior Scales—Second Edition [VABS]) in both children with autism spectrum disorder and developmental language disorder. The connection between communication and social functioning with cognitive and language development in children with hearing loss has been made in a few limited studies.13,47–51 Stevenson et al52 reported that children with hearing loss have lower social function scores than hearing children. In this case, early identification of hearing loss (by 9 months) led to better receptive language skills (measured by grammar and vocabulary assessments). Because language skills continued to remain below the skills of children with hearing, the improvement in language was not sufficient to eradicate the risk of behavioral and functional problems. Horn et al53 found that children with cochlear implants who scored “high” (based on a median split) in the socialization domain of the VABS had higher language than children who scored “low.” The investigators used

Table 4. Results from Linear Regression Models b (SE)

p

Partial R2

Total R2

.49 (.09)

,.0001

.348

.348

Receptive:IQ ratio

.38 (.08)

,.0001

.196

.544

Working memory

2.33 (.12)

.007

.034

.578

Aided SRT/SAT

.17 (.09)

.062

.012

.590

SES index

.17 (.57)

.005

.051

.641

.21 (.07)

.006

.299

.229

Receptive:IQ ratio

.19 (.06)

.004

.137

.366

Working memory

2.33 (.10)

.002

.055

.421

SES index

1.41 (.49)

.005

.104

.470

Sex (male)

26.24 (2.38)

.011

.056

.526

Communication—VABS-IIa Nonverbal IQ

b

Social Function—VABS-II Nonverbal IQ

Social Function—PEDI

c

Nonverbal IQ

.32 (.07)

,.0001

.232

.232

Receptive:IQ ratio

.25 (.06)

.0001

.141

.373

Working memory

2.26 (.10)

.012

.053

.426

.33 (.11)

.005

.073

.499

Age HL identification

not significant (p # .1) in model: degree of hearing loss, having a CI, age at study, age of HL identification. bFactors not significant (p # .1) in model: degree of hearing loss, having a CI, age at study, age of HL identification, aided SRT/SAT. cFactors not significant (p # .1) in model: degree of hearing loss, having a CI, age at study, aided SRT/SAT, SES. HL, hearing loss; IQ, intelligence quotient; PEDI, Pediatric Evaluation of Disability Inventory; SES, socioeconomic status; SRT/SAT, speech reception/ speech awareness thresholds; VABS-II, Vineland Adaptive Behavior Scales—Second Edition. aFactors

202 Functional Communication and Language Levels

Journal of Developmental & Behavioral Pediatrics

preimplant VABS scores, however, to predict postimplant language. McCann et al13 showed that better language abilities were significantly associated with improved functional gains in communication and reading. Even among children with developmental disabilities who are deaf, better language coincides with better development of day-to-day social function skills.32,33 Awareness of functional competencies in the preschool years may help prioritize efforts in primary, secondary, and tertiary interventions so that pathways to independence are promoted.30,54 In the current study, low language in children with above average IQ led to communication scores that were similar to scores of children in the lower IQ groups who had commensurate (cognitive-appropriate) language. The items on the communication domain of the VABS-II for this age group represent receptive and expressive language skills. Therefore, the impact of low language levels on functional communication seems intuitive. Unfortunately, our results indicated that the language levels of children do not necessarily have to be dangerously low to have an impact on function, a point that is often underappreciated by professionals who work with children who are deaf/hard-of-hearing. Socialization on the VABS-II measures functions regarding interpersonal relationships, play and leisure time, and coping skills used in everyday living. The social function domain of the Pediatric Evaluation of Disability Inventory focuses on the social functional skills relevant and necessary for participation in one’s family and community. These skills include peer interaction, problem solving, and selforientation and time orientation. Although children often fell in the “low language” classification, language scores were often low average and not 2 SDs below the mean. Without the understanding of a child’s capability or potential, the language scores alone may not warrant

Figure 1. Mean Vineland Adaptive Behavior Scales—Second Edition Communication Function standard scores with standard error bars for children with low language (cross) and average language (circle) levels across different levels of nonverbal intelligence quotient (IQ). Low language classification defined as a ration of receptive language standard score to nonverbal cognitive abilities that is ,0.80. Mean scores are adjusted for nonverbal IQ, working memory, and socioeconomic status. Degree of hearing loss was not significant in the multivariable regression models. Dashed line at 100 on the y-axis represents the population mean. Vol. 35, No. 3, April 2014

Figure 2. Mean Vineland Adaptive Behavior Scales—Second Edition Social Function standard scores with standard error bars for children with low language (cross) and average language (circle) levels across different levels of nonverbal intelligence quotient (IQ). Low language classification defined as a ration of receptive language standard score to nonverbal cognitive abilities that is ,0.80. Mean scores are adjusted for nonverbal IQ, working memory, and socioeconomic status. Degree of hearing loss was not significant in the multivariable regression models. Dashed line at 100 on the y-axis represents the population mean.

speech-language therapy by traditional standards. The current study conveys the importance of a strong language foundation not only for functional communication skills but for social functioning as well. As the greatest area at risk for impact of hearing loss is in the area of communication, focusing on communication and social functioning is critical in advancing our understanding of needs and supports for long-term success. Executive functions are required for language-based academic and social tasks.55 The Working Memory scale of the Behavioral Rating Inventory of Executive Function (BRIEF) assesses a child’s ability to temporarily store and manage the information required to complete cognitive tasks, such as learning, reasoning, and comprehension.

Figure 3. Mean Pediatric Evaluation of Disability Inventory Social Function standard scores with standard error bars for children with low language (cross) and average language (circle) levels across different levels of nonverbal intelligence quotient (IQ). Low language classification defined as a ration of receptive language standard score to nonverbal cognitive abilities that is ,0.80. Mean scores are adjusted for nonverbal IQ, working memory, and socioeconomic status. Degree of hearing loss was not significant in the multivariable regression models. Dashed line at 50 on the y-axis represents the population mean. © 2014 Lippincott Williams & Wilkins

203

Our findings regarding the relationship between working memory and communication and social functioning are consistent with a growing body of literature, suggesting that poorer executive functioning may be related to poorer speech and language acquisition for children who are deaf or hard-of-hearing.56–62 In our study, better working memory (lower scores on the BRIEF) was significantly associated with higher communication and social functioning in our study, although most children did not have clinically elevated scores.

LIMITATIONS Because the majority of participants were recruited from a single institution, there is potential for the sample to be biased regarding factors such as socioeconomic status or degree of hearing loss (a fairly large number of children had received a cochlear implant). Although our sample was biased by families of higher educational levels (a high proportion of mothers had some college education), this did not affect the strong independent relationships between poor language and social functioning. Our institution has a large catchment area, with some participants traveling quite a distance (some traveled more than 100 miles) to participate in the study. The main objective of this study was to understand the relationship between language relative to cognitive abilities and subsequent communication and social functioning. This relationship did not appear to be confounded by the degree of hearing loss or socioeconomic status nor was it associated with etiology of hearing loss. We did not have information about the duration a child may have been in therapy. Participating in therapy during the time of the study was not associated with functional outcomes. The crosssectional nature of this study limits our ability to understand the development of functional skills over time. Thus, longitudinal studies are necessary to determine how social skills may develop as a function of language in children who are deaf or hard of hearing. Functional and social communication development is not as refined in the age range of the study participants (3–6 years) as in older children nor are the assessments used to determine the extent of social interaction impairments very comprehensive. However, if the functional communication delays are noted at an age when the demand for such skills is not high, it becomes important to watch the pattern of this skill development as children age. Recognizing these delays early may speak to a higher severity or degree of delay, and if not remediated, may have long-term impact at later ages.

CONCLUSION This study sheds new light on the role of language among children who are deaf and hard-of-hearing. Fortunately, universal newborn hearing screening has provided us with great opportunities to identify and intervene early for children who are deaf/hard-of-hearing to establish a strong language foundation. Unfortunately, 204 Functional Communication and Language Levels

even with the advances of early identification and intervention, hearing loss continues to have a life-long impact on independent functioning. It is imperative to identify when language levels are not meeting the child’s capabilities so that we can set appropriate expectations for language growth, thus minimizing the functional impact of a language gap. As clinicians and educators, we should not only strive to meet a child’s potential but we should also be cognizant of the role suboptimal language levels are playing in the day-to-day lives of children who are deaf or hard-of-hearing so that we can intervene appropriately. If we are unaware of a child’s cognitive potential, we will miss the impact of a child’s language skills on their overall functioning. Being satisfied with language levels in the low average to average range for children with greater capabilities does a disservice for all children. ACKNOWLEDGMENTS The authors would like to thank Barbara Peterson and the research team at Boys Town National Research Hospital for their efforts with this study. The authors also extend their appreciation to all the families who participated.

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Book Review Serving the Gifted: Evidence-Based Clinical and Psychoeducational Practice Steven I. Pfeiffer, Routledge, New York, NY, 2013, 248 pp, Softcover with DVD $42.95, Hardcover $130. This book seeks to inform educators, administrators, clinicians, and parents about how to identify and assist gifted students in their development. Steven I. Pfeiffer, a clinical psychologist and educator, as well as previous director of a program for gifted students, describes this population as frequently underidentified, poorly understood, and underserved in the educational system. The book has 9 chapters, with references provided to direct the reader to scientific literature and the popular press. A DVD is included, with handouts for parents and Powerpoint presentations for professionals. I chose this book to review because of my interest in learning more about gifted students, as I have encountered several in my practice. I found it to be thoughtfully written and to apply to a broad audience. Throughout the text, Pfeiffer refers to the existing scientific literature and also acknowledges areas where the science is scant. He refers to personal anecdotes reflecting his experiences with gifted athletes in youth soccer and in enrichment programs. In the early chapters, Pfeiffer introduces the concept of giftedness, including historical background, and the idea that giftedness is a social construct. He describes the broadening of the definition over time, to include not only students who have cognitive abilities and academic achievement in the exceptional range, but also highly creative, accomplished, motivated students, who have the potential to excel. Pfeiffer refers to his “Tripartite Model” construct of giftedness frequently. He notes that the historically narrow view of giftedness may exclude many students

who could excel, given opportunity. Pfeiffer describes giftedness in the visual and performing arts, athletics, and creativity in problem solving, as well as eagerness to explore and learn, as examples of less-traditional views of giftedness. He acknowledges the variability between states in methods used to identify gifted students and in allocation of resources to nurture them. He laments that gifted students who have the potential to excel may not be identified and receive the support they deserve, at times due to socioeconomic disadvantages. Pfeiffer also remarks that a student once identified as gifted may not remain so, due to limited experiences or opportunities or insufficient drive. Later chapters describe ways that gifted students can be served in and outside of the classroom, including mentoring by teachers, coaches and parents, as well as their participation in university enrichment programs. Attributes of effective curriculum models are described. Pfeiffer expresses interest in fostering creativity in gifted students and links creativity to strengths in future leadership potential. He devotes a chapter to the “twice exceptional student,” the gifted student who has a learning or social/emotional disability and the challenges of identifying and serving them. These are the children I have encountered in my practice, and I could relate to Pfeiffer’s accounts of the challenges in these children’s and families’ experiences. Pfeiffer questions the idea that gifted students are more likely to have emotional challenges or to be overall more “excitable” than typical students. He notes that gifted students, particularly

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“twice exceptional” students, are more at risk for bullying. The concluding chapters focus on nurturing the “strengths of the heart” and emotional intelligence of gifted students, to enable them to continue to enjoy learning, feel challenged in a positive way, avoid perfectionism and stress, build social confidence, determine their school and career path, and build leadership abilities. The book concludes with a “FAQ” section, which reviews key points from the text. The DVD handouts would be helpful to parents and professionals as they provide websites with information to help in advocating for a student’s needs. The DVD Powerpoint presentations are brief, and I feel of variable utility; I found the “Myths in Gifted Assessment and Conceptions of Giftedness” a helpful review, and the “Twice Exceptional Student” and “Underachievement and the Gifted” useful tools for professionals to guide parents who are seeking assessment and interventions for their child. Overall, I found this text very readable, with Pfeiffer’s style of review and linking prior concepts helpful and reinforcing. The book is both accessible for parents and useful for teachers and clinicians. Clearly, there are more to be learned in this field on how to help our brightest, most creative, and most motivated young people to excel. Disclosure: The author declares no conflict of interest.

Jeannine R. Audet, MD The Fernandes Center for Children and Families, Steward/St. Anne’s Hospital, Fall River, MA

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