Project ASPIRE:Understanding and Addressing Disparities in Pediatric Hearing Loss

1. Project ASPIRE:Understanding and Addressing Disparities in Pediatric Hearing Loss • Dana Suskind, MD • Professor, Otolaryngology - Head and Neck Surgery & Pediatrics • Director, Pediatric Cochlear Implant Program • University of Chicago Medicine • Sally Tannenbaum, M.Ed., Cert. LSLS, DTH • University of Chicago Medicine

2. CONFLICT OF INTEREST • We have no relevant financial relationships with the manufacturers of any of the commercial products and/or providers of commercial services discussed in this CME activity. • We do not intend to discuss any unapproved/investigative use of a commercial product/device in my presentation.

3. OUTLINE • Impact of poverty on child development and educational attainment • 30 million word gap: foundational impact on early language development • Closing the gap: the Thirty Million Words Project • SES disparities in children with hearing loss • Project ASPIRE: addressing the disparity

4. CHILDREN BORN INTO POVERTY • Income inequality has never been greater in this country • Children are profoundly impacted: 16.1 million children live in poverty • An additional 16.3 million children are living just above the federal poverty line (Addy, Engelhardt, & Skinner, 2013)

5. CHILDREN BORN INTO POVERTY:THE STATS • Racial and ethnic minorities are disproportionately affected • Children under 18 living in low-income families in the United States in 2011: • 11 million (65%) of Latino children • 6.5 million (65%) of African-American children • .4 million (63%) of American Indian children • 12.1 million (31%) of white children • 1 million (32%) Asian children (Addy, Engelhardt, & Skinner, 2013)

6. It’s more than just income. What does this really mean for a child? Poverty impacts every aspect of a child’s life.

7. A LIFE OF POVERTY OFTEN MEANS: • Limited access to • health care • quality education • healthy food • safe play and exercise • Living in more violent and economically depressed neighborhoods • Precarious or unstable housing

8. These factors culminate in significant levels of stress that profoundly impact both parents and children. (Wadsworth & Rienks, 2012)

9. TOXIC STRESS • Extreme or prolonged stress can become ‘toxic’ for children and derail healthy development • ‘Toxic stress’ can negatively impact neural connections in the learning and reasoning parts of the brain • When experienced in early life, this has long-term consequences on a child’s learning, behavior, and physical and mental health (Center on the Developing Child, 201; Toxic Stress: the Facts, 2012)

10. IMPACT ON HEALTH • Impoverished children at greater risk for: • Poor physical health • Chronic health conditions • Behavioral and emotional problems (Hughes & Simpson, 1995; Morgan, 2009)

11. . EDUCATIONAL ATTAINMENT • Only 48% of low-SES children are school-ready by age 5 • 80% or more of African-American and Latino public school students can’t read or do math at grade level in 4th, 8th, and 12th grades (Isaacs, 2012; The state of America’s children, 2011)

12. EDUCATIONAL ATTAINMENT • Dropout rate of low-SES children was 5 times greater than higher-SES children in 2009 • Even the highest-scoring low-SES children are much less likely to finish college than their higher-SES counterparts (Chapman, Laird, Ifill, & Kewal Ramani, 2011; Roy, J, 2005)

13. This educational attainment gap emerges early in children’s lives. But more and more research indicates that the first few years have the biggest and most lasting impact. Clearly, many factors contribute to this gap over a child’s lifetime.

14. At the root of this achievement gap is a disparity in children’s early language environments: how and how much parents talk with their children.

15. THIRTY MILLION WORD GAP • Hart + Risley: • High-SES children: 45 million words by age 3 • Low-SES children: 13 million words by age 3 • This 30 million word gap profoundly impacts children’s vocabularies, test scores, and IQs (Hart & Risley, 1995)

16. DISPARITIES IN EARLY LANGUAGE ENVIRONMENTS • Both quantitative and qualitative • Inequities in parents’ language input include: • significantly less talk and gesture • shorter and less complex phrases • less use of open-ended questions • greater use of directives (Hammer, Tomblin, Zhang, & Weiss, 2001; Hoff & Tian, 2005; Huttenlocher, Haight, Selzer, & Lyons, 1991; Reilly et al., 2010; Rowe, 2008; Rowe & Goldin-Meadow, 2009; Hoff, 2012)

17. DISPARITIES IN EARLY LANGUAGE ENVIRONMENTS • Decreased parental language input leads to significant disparities in children’s development of: • vocabulary • grammar • narrative skills • Early literacy skills • Processing speed • Disparities in language skills are seen from infancy through high school, and the gap widens with age (Hoff, 2012; Fernald, Marchman, & Weisleder 2012; Hoff, 2005; Huttenlocher, Waterfall, Vasilyeva, Vevea, Hedges, 2010)

18. This results in children starting school much less prepared to learn.

19. The multifactorial nature of poverty and its impact on children’s development is certainly staggering • But the profound impact of parents’ language upon development and children’s ultimate trajectories gives us hope Parents have the power to use their words to grow their children’s brains

21. Could we target the SES-achievement gap through an educational program that partners with parents to enrich children’s early language environments? So we asked:

22. THE THIRTY MILLION WORDS PROJECT • 12-week parent-directed behavioral intervention to equip parents with skills to enrich their children’s language environments

23. THE THIRTY MILLION WORDS PROJECT

24. What does this have to do with children with hearing loss?

25. The disparities noted among typically developing children are compounded in children with hearing loss • Early language environments have a profound impact on the outcomes of children with hearing loss

26. TARGETING THE DISPARITY: PROJECT ASPIRE • Parent-directed program designed to enrich the early language environments of children ages 0-4 with hearing loss • Listening and spoken language curriculum • Designed for underserved families but applicable for all • Provided in addition to Early Intervention • Now funded: Dept. Education IES

28. GUIDING PHILOSOPHY • Parents are children’s first and most important teachers • Enriching a child’s early language environment occurs through promoting parent-child interactions that have been linked to positive child outcomes • This does NOT require changing cultural practices and values or idiomatic speech

29. GOALS • Equip parents with knowledge of their child’s brain and language development • Increase parents’ belief that their words have the power to “build their child’s brain” and positively impact their educational outcome • Increase parents’ language input to enrich their child’s early language environment

30. CURRICULUM: MORE THAN JUST “TALK” • Early language strategies include: • child-directed speech • positioning • joint attention • follow the child’s lead • turn taking • wait time and expectant look • routines & repetition • self talk & parallel talk • description and expansion • give choices & open-ended questions • labeling - take the “it” out of your vocabulary • book sharing • eliminate background noise • decreasing TV and technology time

31. INTERVENTION ELEMENTS • Coaching method • One-on-one Home Visiting model • Educational modules • Behavioral strategies • Video modeling • Quantitative Linguistic Feedback • Goal setting

32. PROJECT ASPIRE • Parents are partners • 10 weekly computer-based modules • Integrate practical strategies for increasing parent talk and turn taking into routines and everyday activities • Discussion-based, motivational, non-judgment • Video of parent-child interaction illustrates real-life applications • Animation takes scientific concepts and makes them user friendly

35. BEHAVIOR STRATEGIES: VIDEO MODELING • Interventionist and parent practice new skills on video • Review and discuss using coaching method • Gives parents immediate concrete feedback on implementing strategies

36. BEHAVIOR STRATEGIES: QUANTITATIVE LINGUISTIC FEEDBACK • LENA’s automated technology grants an unprecedented window into a child’s natural language environment • Records 10-16 hours • Measures • adult words • conversational turns • child vocalizations • TV time (Automatic language assessment in three easy steps, 2011).

37. BEHAVIOR STRATEGIES: QUANTITATIVE LINGUISTIC FEEDBACK • Tool for: • awareness of language input • feedback • motivation • goal setting (Automatic language assessment in three easy steps, 2011).

42. PILOT STUDY • Currently ongoing • 32 families in Chicagoland area • Quasi-experimental study • 3-months post-intervention follow up

43. PROJECT ASPIRE: NEXT STEPS • Longitudinal, multi-institutional study • Identify potential partners to make curriculum accessible nationwide • ASPIRE Espanol • Adapt for Telemedicine • Comprehensive professional learning • Web-based Community of Practice for ASPIRE Interventionists

44. IT TAKES A VILLAGE I would like to thank Project ASPIRE’s many collaborators: • Kristin Leffel • Beth Suskind • Eileen Graf • Sally Tannenbaum • Michelle Havlik • Lyra Repplinger • Lia Ferro • Mary Ellen Nevins • Marc Hernandez • Teresa Caraway • Ereni Katsaggelos • Jean Desjardin • Christina Perigoe

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