MATERNAL AND CHILD CHARACTERISTICS DURING MOTHER-CHILD PLAY SESSIONS: ASSOCIATIONS WITH CHILD LANGUAGE OUTCOMES AT 18-24 M FOR CHILDREN WITH CONG N A A NG OSSCONGENITAL HEARING LOSS

April 2, 2009

Presented by AUCD and supported by Cooperative Agreement from the National Center on Birth Defects and Developmental Disabilities (NCBDDD) at Center for Disease Control and Prevention (CDC)

Webinar Agendag2

I Welcome & Introduction – Karla Kmetz Project Specialist I. Welcome & Introduction – Karla Kmetz, Project Specialist, AUCD-NCBDDD Cooperative Agreement

II. Presentation: Child Language Outcomes at 18-24 m for Children with Congenital Hearing Loss

Betty Vohr, MD, Lucille St Pierre BS, Julie Jodoin-Krauzyk, MEd, MA, Deborah Topol, BA, Richard Tucker, BAp

Organization: Warren Alpert Medical School of Brown University Women & Infants’ Hospital, affiliated with Paul V. Sherlock Center on Disabilities (RI UCEDD)

III. Question and Answer

Overview: AUCD-NCBDDD Cooperative Agreement

' Strengthen the nation's capacity to carry out public health and disability activities

Foster collaborations among AUCD, its network (UCEDD, LEND DDRC) members and NCBDDD LEND, DDRC) members, and NCBDDD

Provide technical assistance to State Disability and Health Grantees

E h th it f t t d ti ll b ti Enhance the capacity of states and creating collaborative systems change in the early identification, assessment, service coordination for children with autism spectrum disorder and related disabilities through Act Early Regional Summits

Strengthen expertise in the fields of birth defects and developmental disabilities through training of professionals in public health and related fields.

Facilitate a wide range of research, education, and dissemination activities.

Research Topics of Interests (RTOI)4

RTOI are specific research area of significance identified by scientists at NCBDDD CDC P t RTOI j t h f d th f ll i NCBDDD, CDC. Past RTOI projects have focused on the following areas:

Health Communication and Education P i f S d C di i Prevention of Secondary Conditions

Healthcare Cost Analysis Quality of Life Studies

D l l F d O Developmental Factors and Outcomes Health Promotion Interventions Co-Morbidity Prevalence Studies

Specific disabilities areas include: autism spectrum disorder, Down syndrome, Duchenne muscular dystrophy, epilepsy, Fragile X syndrome, hearing loss, fetal alcohol syndrome, spina bifida, and Tourette syndrome. fetal alcohol syndrome, spina bifida, and Tourette syndrome.

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Maternal and Child Characteristics duringMother-Child Play Sessions: AssociationsMother Child Play Sessions: Associations

with Child Language Outcomes at 18-24 m for Children with Congenital Hearing LossChildren with Congenital Hearing Loss

Betty Vohr, MDL ill S Pi BS J li J d i K k MEd MALucille St Pierre BS, Julie Jodoin-Krauzyk, MEd, MA,

Deborah Topol, Richard Tucker, BA

Women & Infants’ HospitalWarren Alpert Medical School of Brown University

Providence, RIo de ce,

Funded by cooperative agreements between the Rhode Island Department of Health and the Early Hearing Detection and Intervention Program at the Centers for Disease Control & PreventionHearing Detection and Intervention Program at the Centers for Disease Control & Prevention

and the Association of University Centers on Disabilities Grant UR3/CCU120033-01 AUCD-RTOI 2006-06-07-1

Family Perspectives Study

• Prospective study of a cohort of childrenProspective study of a cohort of children born and screened for HL in RI

• Home visits conducted at 6 10 12 16 &• Home visits conducted at 6-10, 12-16 & 18-24mI iti ll f d d b C ti• Initially funded by a Cooperative Agreement between CDC and RI DOH

• Funding received from AUCD for 36 and 48m assessments

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Study Design for Child Outcomes

Maternal Stress Words Hearing Loss

Study GroupsStudy Groups PredictorsPredictors OutcomeOutcome

PCIS Scores

Hearing loss

Produced

at 18-24

Hearing Loss

Typical HearingHearing loss

NICU Stay months

Objective: To assess the effects of maternal stress and maternal communicative effectiveness and hearing loss on words produced at 18 months for children with and

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without congenital hearing loss and to assess the effects of stay in the NICU.

Hypotheses↑ f l th i f t i t ti ill f t• ↑ successful mother-infant interactions will foster improved language outcomes for children with HL and hearing children. a d ea g c d e

• ↑ verbal involvement, Improved affective atmosphere, positive regard and global measures

f (of interaction (atmosphere, availability, and enjoyment), will a be associated with ↑ language skillsskills.

• Controlling behaviors, such as control/directiveness and intrusiveness, will be associated with ↓ language skills.

• ↑maternal stress will be associated with ↓language skills

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language skills.

Study SampleStudy Sample

• Study subjects were children withStudy subjects were children with permanent hearing loss born in Rhode Island from 10/15/02 to 1/31/05 (n=31)Island from 10/15/02 to 1/31/05 (n 31)

Child id tifi d ith t• Children identified with permanent congenital hearing loss were matched to

t l hild ( 40) ith h icontrol children ( n=40)with no hearing loss.

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Methods• Enroll families of infants with HL• Identify control matches• Informed consent: Schedule home visits• Matching Criteria (Gender NICU versus Well Baby• Matching Criteria (Gender, NICU versus Well-Baby

Nursery, Date of Birth (+/- 30 to 90 days), Hospital of Birth, Maternal Education, Race/Ethnicity, Health Insurance)

• Assessments at home visits– Demographics and Hollingshead SES– Parenting Stress Index– Parent Caregiver Interaction Scale

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– MacArthur Bates CDI

•Parent Caregiver Involvement Scale (PCIS)

10 minute play session coded by trained coders10 minute play session coded by trained codersFarran D, 1986

Six areas were coded for amount and quality of b h i di l d b th tbehaviors displayed by the parent

• Verbal Involvement• Responsiveness• Play Involvement• Control/Directives• Positive Regard

12• Negative Regard

Parent Caregiver Involvement S l (PCIS)Scale (PCIS)

Four items were scored on amount as overallFour items were scored on amount as overall indicatorsAvailability Acceptance Atmosphere EnjoymentAvailability, Acceptance, Atmosphere, Enjoyment

Fi it t d i d d tFive items are rated as independent scoresSensitivity, Scaffolding, Intrusiveness, Structuring/Intrusiveness, Hostility

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Definitions for PCISGeneral Impressions of Caregiver InvolvementGeneral Impressions of Caregiver Involvement with Child

• Availability – Parent response based on child’sAvailability Parent response based on child s expressed needs or cues

• Acceptance – Approval and acceptance of childAcceptance Approval and acceptance of child • Atmosphere – Synchrony between adult and child• Enjoyment – Amount of time that adult and child• Enjoyment – Amount of time that adult and child

seem to be delighted with each

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Definitions for PCIS: A C d d f A t d Q litAreas Coded for Amount and Quality• Verbal Involvement – Amount and quality of

caregiver’s verbal communicationscaregiver s verbal communications• Responsiveness- Caregiver’s reaction to child

initiations• Play involvement – Amount and quality of caregiver-

child play during session• Control/Directives Amount and quality of structure• Control/Directives – Amount and quality of structure

and directives by caregiver• Positive regard – Caregiver displays positive attitude g g p y p

toward child.• Negative regard – Negative emotions and

statements directed toward child15

statements directed toward child

Emotional Availability ScalesEmotional Availability Scales• Sensitivity- genuine interest and pleasure with y g p

child. Play creative and joyful for both• Scaffolding-Maintain appropriate level of

structure to allow success for childstructure to allow success for child• Intrusiveness-parenting behavior that prevents

child autonomy. Parent does not let child lead in lplay.

• Structuring/Intrusiveness-degree to which caregiver structures child’s play taking care to ca eg e st uctu es c d s p ay ta g ca e tofollow child’s lead. (Optimal score midpoint)

• Hostility-threatening or frightening interaction

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Parenting Stress Index*•Short form – 36 questions•Likert Scale 1 to 5: Strongly Agree to Strongly Disagree

•Total Stress Score (36-180)Total Stress Score (36 180)•Factor Scores (12-60)

Parental Distress– Parental Distress– Parent-Child Dysfunctional Interaction

Diffi lt Child– Difficult Child

*Abidin RR. Parenting Stress Index (PSI) Third Edition. Lutz, FL: Psychological

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g ( ) , y g

Assessment Resources, Inc; 1995.

CDI at 18m: Words & Sentences*P t I W d Child U i l d 680 it• Part I: Words Children Use includes 680 item vocabulary checklist for words produced and questions on how children use words.ques o s o o c d e use o ds

• Part II: Sentences & Grammar includes questions on word endings, word forms, word combinations, and sentence complexity.

P til il bl f• Percentile scores are available for:• words produced and

sentence complexity• sentence complexity.

*Fenson L Dale PS Reznick JS Thal D Bates E Hartung JP et al TheFenson L, Dale PS, Reznick JS, Thal D, Bates E, Hartung JP, et al. The McArthur Communicative Development Inventories: User's Guide and Technical Manual. San Diego: Singular Thomson Learning; 1993.

Data Analysis Analysis

– Hearing Loss vs. Hearing Controlsg g– T tests to analyze differences between

groupsgroups– Ҳ 2 to analyze differences among

proportionsproportions– Correlations – Regression Models to show relationships of

predictors with outcomes for the total cohort.

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Maternal Characteristics*HL Controls PHL(28)

Controls(30)

P

Age 32±6 35±5 .0987

Married 23(83%) 27(90%) 3859Married 23(83%) 27(90%) .3859

≤high school 2(7%) 1(3%) .5127Primary English 24(86%) 30(100%) .0319

Medicaid / No 4(13%) 6(21%) 4147Medicaid / No Ins.

4(13%) 6(21%) .4147

SES 39±14 48±10 .01

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Total Stress 67±10 70±17 .3892

*Mothers with multiples are counted once and assigned to most severe group

Infant CharacteristicsHL(31)

H Controls(40)

Female 12(39%) 16(40%) .9121

White 28(90%) 39(98%) 1917White 28(90%) 39(98%) .1917

NICU 19(61%) 26(65%) .7476

<37 wks 20(65%) 21(53%) .3093

Visit Age 22.5±2 21.8±2 NS

EI 30(97%) 13(33%) 000121

EI 30(97%) 13(33%) .0001

PCIS Scores for Moderate or High ResponsePCIS Scores for Moderate or High Response

120

100

120hearing lossControl

60

80

20

40

0Verb. Inv. Play Inv. Cont.

Direct.+ Regard Respons. Enjoyment

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Effects of Impact and Resources on Stress Total Cohort

Impact and Parenting Stress Resources and Parenting Stress

s

50607080

ng S

tres

s ea

n )

5060708090

ting

Stre

ssm

ean)

r=.49 R=-.41

304050

20 or less 21-25 26-30 31+

Pare

ntin (m

304050

110 orless

111-120 121-130 131-140 141-150

Pare

n (

Impact Resources

• Increasing impact was associated with ↑ stress• Increasing resources were associated with ↓ stress

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Parenting Stress and PCIS Scores Total Cohort

Parenting Stress and Availability

5ean)

Parenting Stress and Positive Regard

4ard

Total Cohort

01234

50 or 51 60 61 70 71 80 81 90 90+

Ava

ilabi

lity

(me

01234

50 or 51-60 61-70 71-80 81-90 90+Posi

tive

Reg

a(m

ean)

r=-.30 r=-.29

50 orless

51-60 61-70 71-80 81-90 90+

Parenting Stress

less

Parenting Stress

Parenting Stress and Enjoyment

45

mea

n)

Parenting Stress and Verbal Involvement

5

01234

50 or 51-60 61-70 71-80 81-90 90+Enjo

ymen

t (m

r=-.23R=-.41r=.19

012345

50 or 51-60 61-70 71-80 81-90 90+

r=-.29

24

less

Parenting Stress

less

Parenting Stress

Words Produced @18-24 mWords Produced @18 24 mTotal Sample P Sample Excluding Ppincluding NICU

Infants

p gNICU Infants

N HL C l HL C lN HL29

Control40

HL11

Control14

Words 71 ± 112 134 ± 135 0 044 138±159 174±141 0 5496Words

WP %

71 ± 112

17 ± 23

134 ± 135

33 ± 42

0.044

0.003

138±159

31±32

174±141

40±27

0.5496

0.2525

<10th %

20 (69%) 13 (33%) 0.01 5(45%) 2(14%) 0.0849

25

%

PCIS Scores and Words ProducedTotal CohortTotal Cohort

PCIS Availability and Words Produced

PCIS Control and Directives and Words Produced

50

100

150

200

ords

Pro

duce

d (m

ean)

406080

100120140160

ords

Pro

duce

d (m

ean)r=.28

r= 190

3 4 5Availability

Wo

020

2 3 4 5

Control and Directives

Wo r=-.19

PCIS Sensitivity and Words Produced

160180200

(mea

n)

PCIS Atmosphere and Words Produced

160180

ced

r= 21

020406080

100120140

Wor

ds P

rodu

ced

(

020406080

100120140160

Wor

ds P

rodu

c(m

ean)

r=.21r=30

26

03 4 5 6 7 8 9

Sensitivity

Wo 0

2 3 4 5Atmosphere

Parenting Stress and Words Produced

0100200300

W o

r d

s r =-.33

050 orless

51-60 61-70 71-80 81-90 90+

Parenting Stress

W

PCIS Verbal Involvement and Words Produced

Parenting Stress

PCIS Verbal Involvement and Words Produced

50100150

rds

r=.19

050

2 3 4 5

Wo

27Verbal Involvement

Factors Associated with Fewer Words Produced: Correlation CoefficientsCo e at o Coe c e ts

AvailabilityVerbal InvolvementAtmosphere

-.29-.13

-.29

Stress

AtmosphereControl/Directiveness QSensitivity

-.41

-.16-.21

Resources Support

Stress

-.21-.33

.28;.19;.30; .33; .21

HL

Words Produced

-.24.22

NICU-.30

28

Regressions to Predict Words ProducedRegressions to Predict Words Produced

Availability Control Dir Control Dir QAvailability Control Dir Control Dir Q

b p b p b p

NICU -68.2 0.022 -55.9 0.066 -63.1 0.030

Hearing Loss 63 5 0 028 72 1 0 012 74 4 0 008Hearing Loss -63.5 0.028 -72.1 0.012 -74.4 0.008

Total Stress -2.3 0.033 -2.9 0.004 -2.4 0.017

PCIS 26.5 0.160 -30.4 0.097 45.3 0.006

29Total R2 0.27 0.0005 0.27 0.0004 0.32 0.0001

Regressions to Predict Words ProducedRegressions to Predict Words Produced

Atmosphere Sensitivity Verbal InvolAtmosphere Sensitivity Verbal Invol

b p b p b p

NICU -63.7 0.029 -67.3 0.024 -67.8 0.024

Hearing Loss -65.0 0.021 -68.9 0.016 -70.2 0.015

Total Stress 2 5 0 013 2 5 0 018 2 5 0 021Total Stress -2.5 0.013 -2.5 0.018 -2.5 0.021

PCIS 36.3 0.046 15.0 0.225 15.6 0.404

30Total R2 0.29 0.0002 0.26 0.0006 0.25 0.0008

Conclusions at 18-24m• Child HL, NICU stay and ↑maternal stress were

assoc. with words produced at 18-24m.p• maternal control & directiveness during a play

session was assoc with 36 ↓ words whereassession was assoc. with 36 ↓ words whereas Control/directiveness Quality was assoc with 45 more words producedmore words produced

• maternal atmosphere during a play session was associated with 36 more words producedwas associated with 36 more words produced.

• Both maternal and child factors contribute to b f d d d t 18 24 th f

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number of words produced at 18-24 months for children.

• EI Providers should take all maternal andEI Providers should take all maternal and child factors into consideration when developing an Individualized Familydeveloping an Individualized Family Service Plan.

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