Jason Carr, B.A. (Au.D. Candidate),2 Dongxin Xu, Ph.D.,1 and Christine Yoshinaga-Itano, Ph.D.2

ABSTRACT

The Language ENvironment Analysis Language and Autism Screen (LLAS) is an automated vocal production analysis that has been shown to be a valid screener for autism in hearing children between the ages of 24 to 48 months of age. Although there is reportedly a higher incidence of autism among children who are deaf or hard of hearing, the diagnosis of autism is usually later than that in children with hearing. None of the traditional screening instruments have been used with children with hearing loss. Data about the utility of LLAS with children who are deaf or hard of hearing will be presented and discussed. Though more data will be needed, an LLAS at-risk flag in conjunction with the Social Quotient from the Child Development Inventory holds significant promise for a screen for children who are deaf or hard of hearing. KEYWORDS: Deaf or hard of hearing, autism, screen, early childhood Learning Outcomes: As a result of this activity, the reader will be able to describe the sensitivity, specificity, and positive predictive value of the Language ENvironment Analysis Language and Autism Screen for children with normal hearing; (2) discuss characteristics of children who are deaf or hard of hearing that could impact whether their vocal production has characteristics of children with autism and normal hearing; (3) discuss screening tools used with children who have normal hearing and their utility as an autism screen for children who are deaf or hard of hearing.

1

LENA Foundation, Boulder, Colorado; 2Department of Speech, Language & Hearing Sciences, University of Colorado, Boulder, Boulder, Colorado. Address for correspondence: Jason Carr, B.A. (Au.D. Candidate), Department of Speech, Language, Hearing Sciences, University of Colorado Boulder, Campus Box 409, Boulder, CO 80309-0409 (e-mail: [email protected]). Screening, Diagnosing and Implementing Interventions for Children Who Are Deaf or Hard of Hearing

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with Autism Spectrum Disorder; Guest Editors, Christine Yoshinaga-Itano, Ph.D. and Amy Thrasher, M.A., CCC-SLP. Semin Speech Lang 2014;35:266–275. Copyright # 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 5844662. DOI: http://dx.doi.org/10.1055/s-0034-1389099. ISSN 0734-0478.

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Language ENvironment Analysis Language and Autism Screen and the Child Development Inventory Social Subscale as a Possible Autism Screen for Children Who Are Deaf or Hard of Hearing

Autism spectrum disorder (ASD) is clas-

sified as: (1) deficits in social interaction such as eye gaze or sharing interests and emotions; (2) impairments in communication such as problems and initiating conversations; (3) repetitive interests, behaviors, and activities.1 However, little is known about ASD in a population that is deaf or hard of hearing. Current data show that the prevalence of ASD in the general population is 1 in 68, approaching 2% in educational programs for children who are deaf or hard of hearing2 or as high as 6% in children with hearing loss in a recent report from the Centers for Disease Control.3 Jure and colleagues found a 4 to 5.3% incidence of ASD among a population of children with hearing loss, depending upon the criteria used.4 Though the exact percentage of children with hearing loss with ASD is not known, the incidence may be as much as 3 times more frequent within a population of children who are deaf or hard of hearing. There are screening tools for the general population of young children for detection of risk for ASD that have demonstrated good sensitivity, specificity, positive predictive value, and negative predictive value. Sensitivity of a screen its accuracy identifying children who have been diagnosed with ASD (What percentage of the children with ASD did the screen identify?). Specificity of a screen is its accuracy identifying children who are not autistic (What percentage of the children without ASD did the screen correctly identify?). The positive predictive value of a screen is the percentage of children that the screen identified as at risk for ASD who were actually diagnosed with ASD. The negative predictive value of a screen is the percentage of children that the screen identified without ASD who actually were not children with ASD. Kleinman et al administered the Modified Checklist for Autism in Toddlers (M-CHAT) to 3793 toddlers, 16 to 30 month olds.5 Rescreening of 1416 of these children was done at 42 to 50 months. The positive predictive value was 0.36 for the first screen and 0.74 for the screening plus telephone interview. Eaves et al administered the M-CHAT to 84 children aged 24 to 48 months (mean 37 months) who were referred for a full diagnostic autism evalu-

ation.6 Sixty-four percent were subsequently diagnosed with ASD. Sensitivity for the 2/6 critical item score was 77% and for the 3/23 item score was 92%. However, specificity was low at 43 and 27%. Robins et al used a fail cutoff score of 3 of 23 items,7 and Eaves et al used a cutoff score of 3 of 19 items.6 The Robins et al sample was 16 to 30 months of age; the positive predictive value was 36%, and it was 68% after the telephone interview.7 The sensitive, specificity, and positive predictive values differ across studies and populations, specifically high-risk versus low-risk populations. Additionally, the accuracy of the M-CHAT score seems to increase with the age of the child. Currently, no largescale studies using the M-CHAT with children who are deaf or hard of hearing has been conducted. Wiggins et al used the Social Communication Questionnaire (SCQ) with 37 children between the ages of 17 and 54 months and found a sensitivity of 0.47 and a specificity of 0.89 when using a cutoff score of 15.8 When using a cutoff score of 11, the sensitivity and specificity increased to 0.89. There is no current study using the SCQ on children who are deaf or hard of hearing. Allen et al examined the sensitivity and specificity of the SCQ in 81 children considered high risk between the ages of 2 and 6 years of age.9 The sensitivity was found to be 68% and the specificity was 58%. For children aged 3 to 5, the authors noted a sensitivity of 100% and specificity of 62%. The Screening Tool for Autism in TwoYear-Olds (STAT) screen was designed for children 12 to 24 months of age. Stone et al administered the STAT to 70 children who were siblings to children who were referred for an ASD diagnostic evaluation or had a sibling diagnosed with ASD.10 Sensitivity was 0.95 and specificity was 0.73 for the sample of children. The children between 12 and 13 months of age, as well as those later diagnosed with other developmental disabilities, had a lower sensitivity and specificity. There are no studies using the STAT screen with children who are deaf or hard of hearing. Worley et al studied the use of the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT) with children with autism

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LLAS AND THE CDI FOR CHILDREN WHO ARE DEAF/CARR ET AL

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and those with hearing loss due to fluid in the middle ear.11 Traditionally, questionnaires such as the M-CHAT have been used to screen for ASD. The problem with using a parent questionnaire with children who are deaf or hard of hearing is that many parents are not concerned initially about ASD. They believe that many of the behaviors that they observe are caused by their child’s diagnosis of hearing loss. According to Worley et al, symptoms of ASD may overlap with the symptoms of hearing loss.11 Therefore, there is a need for a screening tool for this specific population. The Language ENvironmental Analysis (LENA) is a tool that has been proven effective for screening for ASD in the general population.12 Because newborns are screened for hearing at birth, the probability that a hearing loss will be identified prior to any diagnosis of autism in children who eventually are dually diagnosed is very high. Myck-Wayne et al described the experiences of four families whose children were first diagnosed with a congenital hearing loss and later with autism spectrum disorder.13 Identifying providers with the expertise to separate the two disorders at an early age can be quite challenging, which typically leads to later diagnosis. Oller et al reported a study of 106 typically developing children, 49 language-delayed children, and 77 children with autism, using the LENA Language and Autism Screen (LLAS) with 75% sensitivity and 98% specificity.14 The LENA Web site reported a positive predictive value of 84% and a negative predictive value of 93%. Early intervention has been proven effective in the general population, so it can be assumed the same would be the case with a population of children who are deaf or hard of hearing.15 ASD is most often diagnosed around the age of 3, but can be much later for children who are deaf or hard of hearing, sometimes as late as 5 to 6 years of age.11 In a study of 24 children with autism and hearing loss, Meinzen-Derr et al compared the average age of diagnosis of the hearing loss, 16 months of age, with the age of diagnosis of autism, 66.5 months.16 Only 25% of the children were diagnosed with ASD younger than 48 months of age. Fifty percent of the children were diagnosed with autism and 50% with pervasive

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developmental disorder or Asperger syndrome. Sixty-seven percent had a profound loss, 58% of the children had a cochlear implant, and three of them did not us amplification. Thirty-eight percent of the children used speech as their primary mode of communication. Seventy-five percent of the children with ASD were boys. Twenty-five percent of the children had syndromes such as Ushers, CHARGE (coloboma, heart defect, atresia choanae or choanal atresia, retarded growth and development, genital abnormality, and ear abnormality), or Waardenburg. Rosenhall et al tested the hearing of 199 children and adolescents diagnosed with ASD17; 7.9% of the children had a mild or moderate hearing loss, 1.6% had a unilateral hearing loss, and 3.5% had a profound hearing loss. Thirteen percent of the children with ASD had a significant hearing loss. However, statistics of hearing loss with children with ASD differ, from 0 to 100%. Student and Sohmer found that 100% of the children with ASD had abnormal auditory brain stem results.18 Skoff et al found between 44 and 63% of children had a hearing loss.19,20 This study was designed to investigate whether the LLAS can be used with children who are deaf or hard of hearing. The aim was to assess the accuracy of the LENA autism screen for children who are deaf or hard of hearing when compared with (1) diagnosis of ASD, (2) early intervention provider or parent concern, and (3) the social-emotional subscale on the Child Development Inventory (CDI). There has been an increased awareness of multiple disabilities in the pediatric population of children who are deaf or hard of hearing. However, little is known about ASD in this population. There are no screening tools to assess a population that is deaf or hard of hearing for ASD. The LENA is a tool that has been proven effective for screening for ASD in the general population.12,14,21,22 Children with Asperger syndrome and children with pervasive developmental disorder, not otherwise specified, were excluded in these studies. The question remains if LENA can also be used for a population of children who are deaf or hard of hearing. The LENA screen for autism analyzes recorded acoustical information in a variety of

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STATEMENT OF PURPOSE This project sought to address the need for an accurate screening tool for ASDs in the population of children who are deaf or hard of hearing. However, long-term follow-up of all children to determine referral for a diagnostic evaluation was not possible. Description of the children, any existing concerns regarding development, and results of diagnostic evaluations for ASD of those children who subsequently completed an evaluation will be discussed. Many children who are deaf or hard of hearing with risk factors are not being assessed and diagnosed for ASD until much later than their peers with normal hearing. Early intervention services have proven useful with both the children who are deaf or hard of hearing and the ASD population, so the importance of identifying any children with dual diagnoses is critical for introduction of appropriate early intervention services.

METHODS Participants Ninety-seven possible participants enrolled in the Colorado Home Intervention Program between the ages of birth through 72 months were considered for enrollment in this study.

Any child with missing audiometric data or developmental assessments was excluded from this study. Eighty-three subjects had a LENA recording, developmental assessments, and audiological data. Children with additional disabilities, such as cognitive disorder, were not excluded from inclusion in this study. Eight-three children were included in the analysis. HEARING LOSS

The study included 9 children with permanent unilateral hearing loss and 6 children with a bilateral high-frequency permanent hearing loss. Five children had bilateral auditory neuropathy syndrome disorder (ANSD), 14 children had permanent bilateral mild hearing loss, 19 children had permanent bilateral moderate hearing loss, 9 children had permanent bilateral moderate to severe hearing loss, 9 children had severe hearing loss and 21 children with permanent bilateral severe to profound hearing loss. AGE

The 83 children ranged in age from 6 months to 72 months with an average age of 28.6 months and a median age of 26 months.

LENA Language and Autism Screen LENA is a digital language processor capable of recording 10 to 16 hours of the auditory spoken language environment of a child during a typical day. Parents turn on the recorder in the morning and place the recorder in a pouch on clothing tested to ensure it does not interfere with the recording. The automatic analysis provides information about the estimated number of adult words, conversational turns, and child vocalizations. In addition, it provides information about the acoustics of the language learning environment including the percent of the day in noise and in silence and with TV/ radio and distant language and meaningful language. Detailed information about the definitions of each of these parameters can be found at the LENA Foundation Web site (http://www.lenafoundation.org/). LLAS was designed to automatically and objectively screen for autism in children 24 to 48 months of age. The screen is not extended

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settings and separates that information into different components. The screen can look at minute differences in vocalizations of the child, parents, and electronic devices.23 A typical speech sample is collected by professionals in the field, which limits the components able to be observed to only two or three important factors.23 The LENA autism screen can analyze many more components of the speech signal, including vowel production and overlapping speech, which are characteristic of children with autism.23 Professional observation alone cannot detect the finer nuances of speech and language that are characteristic of the ASD population. The current research hopes to demonstrate the effectiveness of the LENA autism screen to potentially identify children who are deaf or hard of hearing with some form of ASD.

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below 24 months until a sample of children diagnosed with autism can be assessed. In a study of 190 children with 75 identified with autism (not pervasive developmental disorder, not otherwise specified, or Asperger syndrome), the LLAS had a sensitivity of 0.89 and a specificity of 0.87. The positive predictive value was 0.84 and the negative predictive value was 0.93. LENA recordings were analyzed using the commercially available (LLAS) automated autism screen. The LENA LLAS automated screen extrapolates frequencies of different sound categories of child vocalizations of either being phone-based or cluster-based.1 The LLAS has a total of 113 features, 50 bi-phone frequency features, and 63 cluster-based frequency features. LLAS uses a Linear Discriminant Analysis and features characteristics of child vocal “islands,” voicing, syllabicity, spectrum tilt, formant bandwidth, pitch control, duration, and other variables. The LLAS automated analysis had a criterion score from 4 to 7 for referral for additional testing.

Child Development Inventory Parents filled out the CDI every 6 months. The CDI provides age scores for: (1) General Development, (2) Self Help, (3) Social, (4) Expressive Language, (5) ComprehensionConceptual, (6) Fine Motor, (7) Gross Motor, and (8) Situation Comprehension (from the 1972 edition). Age scores are converted to quotients: (Developmental Age/Chronological Age)  100.24 Developmental quotients below 80 are considered outside the range of normal/ typical development. Cognitive quotient has been calculated by the average of Self Help Quotient and Situation-Comprehension Quotient. Doig et al in a study of 63 toddler and preschoolers enrolled in a neonatal high-risk follow-up clinic found that the CDI had a sensitivity of 80 to 100% and specificity of 94 to 96%.25 The CDI had very high relationship with Clinical Adaptive Test/Clinical Linguistic (r ¼ 0.87, p < 0.0001) and for the Bayley Scales of Infant Development-II, Second Edition (r ¼ 0.86, p < 0.001). A social quotient was calculated and analyzed to determine if there were concerns regarding

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social development. A quotient score below 0.8 resulted in a flagged response. The child’s cognitive quotient was compared with the social quotient. If the child’s social quotient was significantly lower than the child’s cognitive quotient, the child was determined to be “at risk.” If a child was flagged on both the LENA and the Minnesota CDI, they were categorized as high risk and would meet criteria for referral. If they were flagged on either screen, they were assessed further based on the Colorado Home Intervention Program (CHIP) Provider concerns. Once the children were organized in risk groups, comparisons were made with the parent or early intervention provider concern and the social-emotional subscale on the CDI to flag the children with the highest concern regarding social skills development. The hypothesis is that those who are most at risk on the LENA autism screen also have concerns in the other two areas. The data will hopefully have great promise as an early screen for children who are deaf or hard of hearing so that appropriate early intervention strategies may be started.

RESULTS Children Referred by Degree of Hearing Loss Category for Each of the Three Methods Using the LLAS automated screen, 16.7% (n ¼ 1/6) of the children with high-frequency hearing loss, 11.1% (n ¼ 1/9) of the children with unilateral hearing loss, 20% (n ¼ 1/5 of the children with ANSD, 14.3% (n ¼ 2/14) of the children with mild hearing loss, 10.5% (n ¼ 2/19) of the children with moderate hearing loss, 22.2% (n ¼ 2/9) of the children with moderate-severe and severe hearing loss and 28.6% (n ¼ 6/21) of the children with severe to profound hearing loss were referred on both the LLAS and the CDI Social Quotient. The total referral rate was 18.1% for all degrees and types of hearing loss combined (n ¼ 15). Fig. 1 depicts the percentage of children referred by the LLAS automated screen and the CDI Social Quotient by degree of hearing loss. The LLAS automated screen showed a high rate of referral. Fifty-four percent

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Figure 1 Depicts the number of referrals divided by degree of hearing loss using the LENA LLAS and the MCDI Social Quotient. Abbreviations: ANSD, auditory neuropathy syndrome disorder; Freq, frequency; LENA, Language ENvironment Analysis; LLAS, LENA Language and Autism Screen; M-CDI; Minnesota Child Development Inventory; Minn, Minnesota Child Development Inventory; Mod, moderate; Sev, severe.

(n ¼ 45) of the recordings were referred on the LENA screen. Of these, 36% (n ¼ 30) were flagged on LENA but not on the CDI Social Quotient criterion. However, almost all of the children who were flagged on the CDI were also flagged on LENA. Only 6% (n ¼ 5) of the recordings were flagged on the CDI Social Quotient Criterion and not the LENA. Eighteen percent (n ¼ 15) of the 83 recordings were flagged on both LENA and the CDI Social Quotient. Fig. 2 depicts the number of children flagged by two of the measures (LENA LLAS and the Minnesota CDI Social Subscale) individually, and in combination, as stated above. When using the double criteria, 15 children in total were referred onto diagnostic measures based on using a double screen of the LENA LLAS as well as the Social Subscale on the Minnesota CDI.

Fig. 2 depicts the number of children who were flagged by LENA LLAS alone, by the CDI Social quotient alone, and by both the LLAS and the CDI SQ. Of these 45 children, 30 were not flagged on the CDI Social Quotient. There are no concerns about these 30 children developmentally from the early intervention providers or the parents at this time. These children, at this time, would be considered as false-positives. Fifteen children were flagged on both the LLAS and the Minnesota CDI Social Quotient. Twenty children were flagged on the CDI using a quotient less than 80, which is a very conservative criterion. Five of these children were flagged on the Minnesota CDI Social Quotient but were not flagged by LLAS. It was determined that these five children had global delays and had been previously diagnosed with other disabilities, such as Down

Figure 2 Flags raised by the LENA LLAS alone, the m-CDI Social Quotient alone, and both of these instruments. Abbreviations: LENA, Language ENvironment Analysis; LLAS, LENA Language and Autism Screen; M-CDI; Minnesota Child Development Inventory.

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syndrome or cerebral palsy. In our database, almost all of the children who are deaf or hard of hearing and identified with ASD had CDI Social Quotients in the 60s or low 70s. The 15 children who were flagged on both the LENA LLAS and the CDI Social Quotient are children for whom concerns have been previously expressed about an additional disability. Of the 15 children who were referred based on these two criteria (LLAS and CDI Social Quotient), three have since been diagnosed with ASD. Four of the 15 children either have recommendations for referral for a diagnostic evaluation for ASD or are being considered for referral. Two of the children were referred for a diagnostic evaluation and were diagnosed not with ASD but with other communication disorders in addition to deafness/ hearing loss, apraxia, and speech-language disorder. Two were identified late and have global developmental delays. Early intervention providers understand the complexity of identifying very young children who are deaf or hard of hearing with an additional disability of ASD. They are also committed to the earliest identification of this dual diagnosis as possible so that appropriate interventions can be provided for these children and families. The clinical psychologist who conducted the diagnostic evaluation for ASD was and will be blinded to the results of the LENA LLAS for any future evaluations of these children.

DISCUSSION Special caution should be taken when referring children who are suspected of having any form on ASD. Although it is suggested by the authors that a double screen is the most appropriate protocol to follow when making decisions regarding if and when to refer, it is possible that some children who are not flagged will have developmental concerns significant enough to warrant further diagnostic evaluation. LENA LLAS was processed on recordings of children as young as 6 months of age. We do not know the accuracy of LLAS for this age, as it was validated against a group of children diagnosed with autism at much older ages. The

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vocal production of the majority of children flagged by LLAS differed significantly from children who are deaf or hard of hearing and were developing intelligible spoken language. Some of these children had characteristics of children with hearing loss identified late, such as “cul-de-sac” resonance. Some of the children were later diagnosed with other speech disorders, such as apraxia, which has a negative impact on the vocal production of children who are deaf or hard of hearing. Children who are identified late and have significant discrepancies between their cognitive status and their language development may display autistic-like behaviors. When the autistic-like behaviors decrease as the child’s language increases, concerns related to ASD diminish significantly. Case studies of children who were deaf or hard of hearing and later diagnosed with ASD are presented in this issue and indicate that the Social Quotient of the CDI is within the normal range for children younger than 15 to 18 months of age but subsequently drops between 18 and 36 months of age for children who were later diagnosed with autism and hearing loss (see Kellogg and colleagues in this issue).26 Therefore, the pairing of the Social Quotient with the LENA LLAS screen is likely most accurate after the age of 15 to 18 months. Using the LLAS alone, children with the most severe to profound hearing loss had the highest percentage of children referred. On the LLAS screen alone, two-thirds of the children were flagged. Twenty-eight percent of the children with severe to profound hearing loss were referred using a double screen criterion. Using the LLAS alone had a high rate of referral. Fifty-four percent of the recordings were referred on the LENA screen. Of this 54%, 36% were flagged on LENA but not on the CDI Social Quotient criterion. However, almost all of the children who were flagged on the CDI were also flagged on LENA. Only 6% of the recordings were flagged on the CDI social Quotient Criterion and not the LENA. Eighteen percent of the 83 recordings were flagged on both LENA and the CDI Social Quotient. Three of the children in the study sent onto full diagnostic measures were subsequently

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diagnosed with ASD. Interestingly, all three of them were referred using the double-screen criteria of the LENA LLAS and the Social Subscale on the CDI. Fortunately, because assessments were taken at different intervals, there is much more information regarding their development. These children varied in their ASD characteristics, based on the assessments gathered. There is little known about the effects of ASD on a child with hearing loss, as there is so much variability in the disorder. However, based on this small case study and analysis, some common themes have presented themselves. First of all, expressive language is delayed with children with a dual diagnosis of ASD, despite the fact they were identified early and had good access to spoken language through early amplification. All three children with ASD had their strongest abilities in letters and numbers. The biggest identifier for a child with hearing loss and ASD is that they all showed significant decreases in their developmental quotients, either because of loss of skills or failure to develop new skills at a rate commensurate with typical social, self-help, and situational comprehension development. No child is alike, but it can be assumed from these limited data that the hallmarks of ASD still exist with children who also have hearing loss. All three children had Social Quotients below 80. The first child, with a profound hearing loss, was slightly behind in auditory and language development than his peers. His strengths, based on the Minnesota CDI, were in the areas of gross motor, fine motor, numbers, letters, and self-help. Using these skills to his advantage in intervention strategies may be useful. Although he was behind on expressive language development, he did show near normal development in symbolic play with objects. His hearing loss may not have had much input on why he was delayed in multiple areas because he was a good hearing aid user before receiving his cochlear implants. He was receiving substantial auditory benefit, and he developed spoken language skills with cochlear implants. Language comprehension was the only score that fell below an age quotient of 60. He mainly uses spoken English as his primary mode of communication, with limited sign language.

The second child is doing quite well for having both an ASD and a hearing loss diagnosis. It could be due to the fact that he was identified with severe hearing loss and fit with hearing aids shortly after birth, but he scored above the age quotient of 80 in almost all categories except three. The three areas that evidenced a deficit were the social, self-help, and situational comprehension portions of the data. This profile is similar to those of the three case studies (see Kellogg et al in this issue).26 Children diagnosed with ASD also have a tendency to exhibit global developmental delays, which are evident in the developmental profiles of two of the children identified with ASD.27 The third child was more globally delayed than the other two children in this study. There are only three areas in which he developed at a normal age level: letters, numbers, and fine motor. His skills in language, both expression and comprehension, were significantly delayed, as was his gross motor development. The third child is interesting because he has a mild hearing loss. His language delays were significantly lower than would be anticipated for his degree of hearing loss. This article represents a descriptive analysis of the utility of an automated vocal production screen for children with the dual diagnosis of hearing loss and autism. Additional data on a larger group of children who are deaf or hard of hearing needs to be collected. An overall profile of a child who is deaf or hard of hearing that indicates Social Development outside of the normal range in addition to an LLAS risk for autism should be looked at in addition to factors such as the development of gesture, symbolic play, self-help, joint attention, eye gaze, and language development. The analysis provides one more piece of information about the overall development of the child with hearing loss. The LLAS provides additional information about the characteristics of the acoustics of the vocal production of children who are deaf or hard of hearing with concerns about additional disabilities, not currently available through other assessments. In addition to parental and early intervention provider concerns and social developmental delays, the LLAS can help provide a more comprehensive picture of the child’s

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characteristics and can help in the differential diagnosis of children with complex developmental profiles.

10.

ACKNOWLEDGEMENTS

This research was supported by the Disability Research and Dissemination Center (DRDC) through its Cooperative Agreement Number 5U01DD001007, from the Association of University Centers on Disabilities, and from the Centers for Disease Control (CDC) and Prevention.

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Language ENvironment Analysis Language and Autism Screen and the Child Development Inventory Social Subscale as a possible autism screen for children who are deaf or hard of hearing.

The Language ENvironment Analysis Language and Autism Screen (LLAS) is an automated vocal production analysis that has been shown to be a valid screen...
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