Children with mild to moderate sensorineural hearing loss are at higher risk for language difficulties compared to normal hearing children. Based on parental reports and language assessments: - Around 40% of children with hearing loss had difficulties with phonology, while 15-17% had deficits in vocabulary, grammar, and reading comprehension. - About 15% of children with hearing loss met the criteria for a clinically significant language deficit. Those children with hearing loss and language deficits tended to have lower nonverbal skills and were more likely to have a family history of language problems compared to children with hearing loss but no language deficits. Early identification of hearing loss and access to intervention can help reduce risks to language development.

1. Language disorder in sensorineural
hearing loss (SNHL)
Outi Tuomainen,
Speech Hearing and Phonetic Sciences
o.tuomainen@ucl.ac.uk

2. Diagnosis of SNHL
• Early identification of permanent congenital hearing impairment is
linked to better speech and language outcomes.
• Universal Newborn Hearing Screen Programmes (UNHS):
“The parents of all babies born or resident in England should be offered hearing
screening for their baby within 4 to 5 weeks of birth.”
• In UK, routine screening for bilateral SNHL > 40 dB HL
• Mild, unilateral, and/or delayed-onset SNHL is often detected in the
community, via parental/clinician/teacher concern, or via school-entry
screen, or it may remain undetected.

3. Language outcomes in SNHL
• Traditionally considered higher risk for difficulties or
deficits in spoken language and reading.
• Difficulties reported for all aspects of language: speech
sounds, vocabulary, sentences (grammar), reading…
• However, considerable individual differences!

4. A FOLLOW-UP STUDY [Tomblin et al., 2015]:
• Accelerated design, 3 year period (audiometry, speech perception and
production, language, literacy, social and academic outcomes)
• 290 2- to 7-year-old children with mild-to-severe SNHL vs 112 age- and SES-
matched normally hearing (NH) children
• SNHL group scored below standardised norms on all language measures
(morphosyntax worse than semantics) and lower than matched controls.
• Faster rates of language growth associated with:
– Better aided audibility; earlier fitting of aids
– But, children fit > 18 months improved language as a function of amount of
hearing aid use
• Results suggest that mild to severe hearing loss places children at risk for
delays in language development; risks moderated by early and consistent
access to hearing aids
Language outcomes in SNHL

5. Language: “input” matters!

6. Predictors of outcomes
• Age of detection
• Age of intervention (earlier = better!)
– Particularly critical for profound SNHL
– c.f. Not so for mild SNHL
• Quality and quantity of hearing aid use
• Family involvement
• Socio-economic status
• Nonverbal ability
• Severity of hearing loss
• Auditory processing [Halliday et al., 2017a]
• Developmental Language Disorders(?) [Halliday et al., 2017b;
this talk]

7. In sum…
• The quantity and quality of the language young children are exposed
to early in life predicts their later linguistic and cognitive skills.
• MMHL leads to altered speech input (both distorted and quieter) that is
not fully rectified by the hearing aids.
• Speech input is different in these children compared to their normally
hearing peers:
Q: What aspects of language children have difficulties with (and what aspects are
possibly “spared”),
Q: What percentage of children have language difficulties, and
Q: Can we “predict” which children will develop language difficulties.
Halliday, Tuomainen, & Rosen (2017). JSLHR.

8. The components of language
• PHONOLOGY: producing and understanding speech sounds and distinctions
between sounds (pea – bee).
• GRAMMAR (syntax and morphology): combining words into sentences, using
endings such as –ed for past tense (walk – walked), understanding meaning of
complex sentences (The cat the cow chases is black).
• SEMANTICS: vocabulary (receptive/expressive); understanding of meanings
expressed by words and word combinations.
• PRAGMATICS: language use; making communications appropriate to the
context, understanding what other person needs to be told.

9. Language and cognitive assessments (1)
1. In-house questionnaire about medical, neurological, psychological history (e.g., family
history of language difficulties/disorders).
2. Children’s Communication Checklist (CCC-2): a parent/teacher checklist aimed to screen for
communication problems in children aged 4-16 years.
Measures: phonology, syntax, semantics, pragmatics: coherence, inappropriate
initiation, stereotyped language, use of context, nonverbal communication, social
relations, interests:
“Leaves off past tense –ed endings”
Options range from “Less than once a week” (or never) to “Several times a day” (or
always)
GCC
General communication
composite (≤55)
“Language disorders”
SIDC
Social Interaction
Deviance Composite
(GCC ≤ 55 and negative
score)
“Autistic spectrum”

10. Language and cognitive assessments (2)
PHONOLOGY
nonword repetition test
“skriflunaflistrop”
SEMANTICS
Vocabulary (understanding
and production)
“What does THIEF mean”
GRAMMAR
Grammar (understanding,
production)
“The girl is chased by the
duck”
Sentence repetition
READING
Word and nonword reading
“water, salder”
NONVERBAL REASONING
Visuospatial skills

11. Children who took part (recap)
MMHL children
(N=46)
Children without HL
(N=44)
Age (years) 11;4 (8.5-16.4) 11;5 (8.0-15.9)
Gender (girls:boys) 19:27 25:19
PTA threshold 46.0 (27.5-69.2) 8.9 (0-15.8)
HL confirmed (months) 53 (2-179) N/A
Hearing aids 93% 0%
Nonverbal reasoning 55.6 (40-78) 60.6 (40-78)

12. Do children with MMHL have language
difficulties? Questionnaires
MMHL children
(N=46)
Children without HL
(N=44)
Family history 24% 20%
Speech therapy 67% 23%
Maternal education (age) 19;3 20;5
GCC 44.5 81.1
SIDC 4.8 1.2
GCC
General communication
composite (≤ 55):
“Language disorders”
SIDC
Social interaction
deviance composite
(GCC ≤ 55 + negative
score):
“Autistic spectrum”

13. Do children with MMHL have language
difficulties? Language assessments

14. What percentage of children with MMHL have
language difficulties?
Percentage of children (in NH and MMHL groups) with language difficulties
MMHL
children
(N=46)
Children
without HL
(N=44)
Phonology 39% 0
Vocabulary (R) 17% 5%
Vocabulary (E) 15% 2%
Grammar (R) 15% 0
Sentence recall 9% 0
Reading (words) 11% 0
Reading
(nonwords)
15% 5%
Parental report (HL):
67% GCC scores
“Language impairment”
11% scores indicated
“Autistic spectrum”

15. • Are these differences clinically significant? [McArthur et al., 2008]
READING IMPAIRMENT
MMHL: 5 (11%)
NH: 2 (5%)
LANGUAGE DEFICIT
MMHL: 7 (15%)
NH: 0
What percentage of children with MMHL have
“language deficits”?

16. • Higher proportion of children in the MMHL group showed evidence of
clinically significant language deficits.
– How can we identify these children as early as possible?
– How do they differ from the peers?
• This would help us understand and predict language difficulties in
children with MMHL.
Which children with MMHL have “language
deficits”?
MMHL good language
N=34
MMHL language deficit
N=12
GCC
Phonology
Vocabulary (R, E)
Grammar
Sentence recall
Reading (W, NW)

17. Language
“Good” “Deficits”
N 34 12
Age (years) 11.4 (2.1) 11.4 (2.4)
Nonverbal skills 57.6 (8.5) 50.1 (6.7)
PTA 47.1 (11.9) 42.8 (12.0)
Age confirmation (months) 50.7 (32.9) 64.6 (41.9)
Maternal education (yrs) 19.9 (2.7) 17.8 (2.0)
Family history 5 (15%) 6 (50%)
Which children with MMHL have “language
deficits”?

18. Q and A:
• Do children with mild to moderate HL have language difficulties?
– As a group: no and yes (parental reports and oral language
assessments); phonology
– BUT as a group the differences were not clinically significant
• What percentage of children with MMHL have language
difficulties?
– A significant proportion of children with MMHL, indicating an
increased risk of experiencing difficulties with language

19. • Which children with MMHL have clinically significant “language
deficits”?
– Nonverbal skills: better skills support the language development?
(protective factor)
– Family history of language and/or reading problems with MMHL: a greater
likelihood that the child will go on to experience language difficulties
(risk-factor)
Q and A:

20. Thank you!