Project ASPIRE: Empowering Families of Children Wit h Hear ing Loss
Sophie Shay, MSII Lyra Repplinger, M.S. Dana L. Suskind, M.D. AdAgenda
{ Proj ec t ASPIRE { Exploring Health Disparities { Developing A Best Practices Curriculum { The Modules { Module Components { The Dream { Research Protocol/Pilot Testing { Q & A What i s P roj ect ASPIRE?
{ Proj ect ASPIRE: Achiev ing Superior Parental Involvement for Rehabilitative Excellence z A comprehensive interactive multimedia intervention z Imparts knowledge and skills for parents of economically disadvantaged children to aid in their children’s listening, language and spppeech development after im plantation z Empowers parents Impetus for the Program: IltOtImplant Outcome Di Diitisparities
{ Econom ica lly disa dvan tage d imp lan t rec ip ien ts have less favorable outcomes than their more affluent peers (Witkin, 2005;Easterbrooks, O’Rourke & Todd, 2000) { Factors in Outcome Disparities z Access and Availability of Habilitation z Inadequate Parental Skills to support their child’s language development (Geers, 2006; Moog & Geers, 2003, Easterbrooks, O’Rourke & Todd, 2000) What A re H ealth Dispar ities ?
{ Unequal burd en in disease morbidit y and mort alit y rat es experienced by ethnic/racial groups as compared to the dominant group { Widening disparity in the United States affecting all aspects of healthcare { Socioeconomic status (SES): the most frequently cited, and most consistent, contributor z SES=income, education, wealth or a combination { Healthy People 2010 has designated the elimination of health disparities as one of its essential goal z Improved hearing health of the nation through prevention, early detection, treatment and rehabilitation z Successful Implantation and Habilitation of Children Makes good economic sense! Children an d Pover ty
BELOW 100% BELOW 150% RACE POVERTY** POVERTY** White 13.8% 24.3% Black 32.6% 46.9% Asian 11.3% 18.9% Hispanic 26.6% 45.6% All Children 16.9% 28.1%
** Percentages from 2006 data Health Disparities in Pediatric Cochlear Implantation
{ Dispari t ies in Hear ing-IidImpaired EhiEthnic Minorities: A Double Jeopardy { Early Hearing Detection and Intervention (EHDI) z Loss to follow-up after failed initial screening occurs in 59.9% of the children z ethnic minorities or publicly insured are 1.5 to 2x more likely to be lost after failing the newborn screening { Implantation Rates { Auditory, Speech and Language Outcomes Understandingggp and Addressing Disparities Horn & Beal (adapted)
Disparities in Implantation Disparities in Outcomes
Root Causes
Individual Health Systems Community Society
Interventions
Equity in Equity in Implantation Rates Auditory, Speech, and Language Outcomes Health Disparities in Pediatric ChlICochlear Imp lttilantation
{ 2008 national survey of pediatric audiologists “Si“Socioeconomi c DtDetermi nant s of PPditiediatric Cochlear Implant Success” (Kirkham, Perry, Baroody, Nevins & Suskind) z 78% (n=98) of pediatric audiologists noted a negative effect of SES on outcomes z This disparity attributed to internal & external factors { parentallfffl self efficacy, ad vocacy and ddh adherence { access and quality of habilitation and resources z Overwhelming agreement that increasing parental involvement in habilitation would be most effective strategy for reducing outcome disparity Proj ec t ASPIRE C o lla bora tors
{ Headquartered at the University of Chicago, Pro jec t ASPIRE coll ab orat ors incl ud e: z Medical Director & PI, Dana L. Suskind, MD z Educational Consultants, Lyra Repplinger, MS, Mary Ellen Nevins, Ed. D. & Jean DesJardin, Ph.D . z Health Disparities Expert, Sarah Gehlert, Ph.D. z Linguistics & Psychology Consultant, Amy Franklin, Ph.D. z Interactive Multimedia Expert, Dr. Cammy Huang z Research Associate, Renate Schultz, B.A. z Script Writer & Social Worker, Ms. Leslie Lewinter z Animator MIT, Fardad Faridi z Sean Adibs, Producer/videographer z Cree Rankin, Director z John Paro, Songwriter/medical student Concep tuali z ing Pro jec t ASPIRE
{ 8 Int eracti ve Multi medi a Sess ions { Professionally Supervised, Parentally Directed Group Sessions { Project ASPIRE Module Components z Animated introduction z Modeled behavior video z Practice new behavior z Carryover activity Developing a Best Practices CilCurriculum
{ A number of parent education/skill building programs are already in existence { These were consulted for developing the themes and key points of each of Project ASPIRE modules FtiStdiPfdFormative Studies Performed
{ Parent Focus Groups and Individual Interviews { Assess Barriers and Motivators { Cultural Sensitivity of material { Understand Baseline Knowledge and Beliefs Iden tifyi ng M od ul e T opi cs
{ Curriculum review and consensus building discussions with other educational experts yielded 8 areas for information dissemination and skill building for the Project ASPIRE pilot Module One: What i s P roj ect ASPIRE?
{ Core Instruction z critical role of post implant habilitation z key ro le o f pa re nt invo lve me nt { Key Points z parents are partners z implant activation is a beginning, not an end z wear time necessary for success Module Two: Setting the Stage for Good Listening
{ Core Instruction: z Ling Six Sound check necessary to determine device functioning z rediducing bbkackground noi se hhlelps the child listen { Key Points: z daily equipment check is critical to success z good acoustic environment supports listening and talking Module Three: SdSfi/BthASound Safari/Be the Announcer
{ Core Instruction: z parents play an important role in calling attention to, labeling and describing sounds in the environment { Key Points: z understanding what sound means is different from just hearing it z parents provide labels for the sounds the child hears to help create a sound/word inventory Module Four: How to talk so your child learns to listen and speak
{ Core Instruction: z use of Child-Directed Speech helps children listen and learn { Key Points: z rate, pitch and acoustic highlighting are elements of CDS z using an “interesting” voice helps a child know when speech is being directed to him/her Module Five: Be a Copycat …Talking Starts with Imitating Sounds
{ Core Inst ruction : z speech production is assisted by imitating sounds that the child produces { Key Points: z imitating a child’s sounds reinforces the conversational attempt and allows the parents to take a turn z over time, parents help shape these sounds into meaningful words Module Six: Tell Her/Him About It. It’s as Easy as 1, 2, 3
{ Core Instruction: z reprises the importance of CDS and conversational turns z adds element of language expansi on { Key Points: z after labeling, parents provide more information about a word by using it in a phrase or sentence z using the word in yet another context helps broaden the child’s understanding Module Seven: Getting Ready for Reading by Book Sharing
{ Core Instruction: z it is important to build vocabulary from the start to get ready for reading { Key Points: z the words a child learns today prepare him/her for reading in later years z Sharing and reading books is critical to language learning and later reading achievement Module Eight: From Empowerment to Advocacy: Knowledge is Power
{ Core IttiInstruction: z Through Project ASPIRE, parents gain new knowledge and skills to best help their child develop listening and spoken language. { Key PPitoints: z Review Local Educational Resources, Parent Support Groups, etc z Don’t be afraid to stand up for your child! AiAnima tion: ThChThe Charac ters
{ Star { Stella { AdiAudi { The Doctor { SkSpeak Lee { Moose the Mouse { The Camera Man Star
{ MiMain character { Young mother { Provides information from an “I’ve been there” perspective Stell a
{ Bilatera l imp lant recipient { Animation depicts both a younger, newly-implanted Stella and Stella as an experienced listener AdiAudi
{ The audiol og ist delivers important information to Stella and serves as her support The Doc tor
{ RiRepresentative of the medical component of the process of implantation SkLSpeak Lee
{ This character is introduced as the director of the video recordings that parents will be asked to do MthMMoose the Mouse
{ This “com ic re lie f” character is a representation of the computer mouse that serves to gain access to the computer/DVD modules The Camera Man
{ This character assists the Director in capturing the images of parent- child dyads Pro jec t ASPIRE
Videos Pro jec t ASPIRE
The Pilot Study, Phase 1 The University of Chicago Pilot study of Project ASPIRE
{Hypothesis: Within fffamilies of low SES background, completion of the Project ASPIRE pilot program will: z Improve parental knowledge of their hearing impaired child’s language development and listening needs z Positively affect parental behavior – increased adult language input, conversational turns, and decreased background noise Methods
Study Participants Study Design
The U of C Pediatric Baseline LENA recording Hearing Loss and Cochlear and questionnaire Implantation Program
One 1-1/2 hour Low SES background intervention/teaching session
1-week, 2-week, and 4- n=8 families who have a week post-intervention child with varying degrees audio recordings and of hearing loss questionnaires { LENA (Language Environment Analysis) System 1. Adult Word Count (AWC) 2. Conversational Turn Count (CTC) 3. Television Exposure {Dig ital Language Processor (DLP)— recorddding devices worn bhby the child for 16 hours
http://www.lenafoundation.org THE INTERVENTION
{ Powerpoint presentation format { Coaching Method employed { Therapist and family view it together { Intervention is interactive z Questions z Role Play z Parent Involvement and Input THE INTERVENTION
{ The therapist visits the family at their home { Intervention taklkes approximately one hour. { At the end of the Interventi on, the family is given another DLP and is asked to do a future recording. The3TThe 3 Ts’s
1. Talk more to child 2. Take turns talking 3. Turn of the TV RltResults
{ Parental Knowledge Questionnaires { LENA System Outputs z Adult Word Count z Conversational Turn Count z Television Exposure
{ CltiCorrelations btbetween paren tltal knowledge and behavior Results Parental Knowledge Questionnaires Scores
10 9 *** 8 * p<0.01 7 ** p<0.05
ore 6 cc 5 4
Test S 3 2 1 0 Baseline (n=8) 1-week (n=6) 4-week (n=5) Results LENA System Output
Mean Adult Word Count Mean Conversational Turn (*p<0.100) Count (*p<0.100)
24000 1000
22000
rns 800 ords uu 20000 * 600 18000 * er of W
ber of T 400 bb 16000
Num 200
Num 14000
12000 0 Baseline 1-week 2-week 4-week Baseline 1-week 2-week 4-week (n=8) (n=8) (n=6) (n=5) (n=8) (n=8) (n=6) (n=5) Results Questionnaire Scores and LENA Output
Change in AWC and Change in CTC and Questionnaire Scores Questionnaire Scores Baseline to 1-week post- Baseline to 1-week post- iiintervention intervention
r2=0.679 r2=0.584 ANOVA p<0.05 ANOVA p<0.05 Results LENA Output: Television Exposure
Mean Duration of TV Exposure Paired samples t-tests insignificant at 1-week, 2-week, and 4-week post intervention
4
3
2 Hours 1
0 BliBaseline 1-week 2-week 4-week (n=8) post (n=8) post (n=6) post (n=5) Study Limitations
{Small sample size (n=8) z Low detection power z Hig h between-subjects variat ion in AWC, CTC, and TV exposure
{Hawthorne Effect Pro jec t ASPIRE
The Pilot Study, Phase 2 The University of Chicago What’ s N ex t
{ Participants will be given feedback reports withlfhh results from their LENA recordings
{ Participants will create weekly goals and will see the ir progress through the LENA printouts The3TThe 3 Ts’s
1. Talk more to child 2. Take turns talking 3. Turn of the TV Talk More
Adult Word Count Example Progress Report – Adult Words 98th Percentile 95th percentile 90th Percentile
80th percentile 75th percentile oken 50th pp percentile 45th percentile 0 ords S 005 ,, 11 WW 37 28,3 17,651 23,338 16,388 12,279 Adult 1,339 1 #2 #1 #1 #2 Best Baseline Baseline Recording Above Average Average Recording Take Turns
Conversational Turns Example Progress Report – Conversational Turns
99th 99th 95th percentile percentile percentile urns TT 86th percentile 75th percentile th
ational 68
ss percentile 50th percentile 952 onver CC 870 500 330 ber of 233 288 389 mm Nu
Average Above Best #2 #1 #1 #2 Average Baseline Baseline Recording Recording Turn off the TV Audio Environment Example Progress Report—Total Daily TV time
400 n 300 was o VV
200 inutes T
1 hour 38 min 100 1 hour 27 min Total m 0 hours 30 0h0 hours 38 min min 98 87 30 0 38 Baseline Baseline Recording Recording #1 #2 #1 #2 What we l earned
{ The Relationship with the family should be established prior to the administering the intervention. { Interactive interventions were the most successful { Don’t PREACH…PLAN and be their PARTNER! Qti&CQuestions & Commen ts