The impact of communication possibilities on psychosocial difficulties in children with hearing loss

Main study parameter/endpoint

Psychosocial difficulties as estimated with the HEAR-QL, and the CBCL, TRF, and

YSR.

Auditory functioning as estimated with pure tone audiometry, speech perception

in quiet measured with the NVA for soft speech, speech intelligibility in

noise, measured with the Digits in Noise test (DIN).

Vocal emotion score as estimated with the EmoHI emotion recognition test, and

with the vocal emotion expression test.



Psychosocial difficulties

HEAR-QL

The Hearing Environments and Reflection on Quality of Life questionnaire is a

valid, reliable and sensitive quality of life assessment tool for children with

hearing loss (35). It is available in two versions, one for children (7-12 yrs)

and one for adolescents (12-18 yrs). The child version consists of 34 questions

divided into the four subscales: hearing loss, environment, activities,

emotions. The total scores can range from 26 to 130, where 26 indicates no

difficulties on any scale and 130 indicates most difficulties on all scales.

The adolescents version contains 36 questions, divided into the four subscales:

listening, social, school, emotions. The total scores can range from 29 to 145,

where 29 indicates no difficulties on any scale and 145 indicates most

difficulties on all scales. The child- and adolescent*s version can be found in

appendix 2a and 2b respectively.

The HEAR-QL is part of the clinical routine, it may be that children have

already filled out the questionnaire. Children that have not filled out the

questionnaire, or their submission is more than six months ago, are required to

fill it in as part of this study. The duration of administration is 10 minutes.

The HEAR-QL will be filled out by the participants. This will be done online,

at home.

The HEAR-QL will serve as the outcome measure for the participants* hearing

related quality of life and coping with social situations.



Child Behavior Checklist (CBCL), Teacher Report Form (TRF), Youth Self Report

(YSR)

The CBCL (36) is a parent report form to screen for emotional, behavioral, and

social problems in children between 6 and 18 years of age. It will serve as the

assessment of the participants* psychosocial difficulties. The CBCL contains a

total of 113 questions in eight different categories: anxious/depressed,

withdrawn/depressed, somatic complaints, social problems, thought problems,

attention problems, rule-breaking behavior, and aggressive behavior. The CBCL

also has a scale set to show scores associated with disorders from the

Diagnostic and Statistical Manual of Mental Disorders (DSM) (37): anxiety,

oppositional defiant disorder, conduct problems, somatic problems, affective

problems, and attention deficit disorder. Many studies have demonstrated a high

rate of reliability between the scales of the CBCL and psychological diagnoses

(38). Teacher and Child versions of the CBCL are also available. Those are the

Teacher Report Form (TRF) and the Youth Self Report (YSR). The Dutch CBCL, YSR

and TRF can be found in appendix 3a, 3b, 3c respectively.

The problem items can be completed by most parents and teachers in about 10

minutes and the competence items in another 5 to 10 minutes. This will be done

online, at home.

The CBCL, YSR, and TRF will serve as outcome measures for the participants*

mental health and psychosocial difficulties. Additionally, the school

performance section in the CBCL and TRF will serve as an indicator of

intelligence.



Audiometry: pure tone/speech/Digits in Noise



Pure tone audiometry

Hearing levels are obtained in a sound-proofed booth. Hearing is measured with

a clinical audiometer. Pure-tone air-conduction thresholds are obtained at

frequencies 0.5, 1, 2, 3, 4, 6, and 8 kHz by an experienced audiometrist.

Thresholds are defined by the intensity level at which the tone was heard in 1

out of 2 ascents, resulting in a true clinical audiogram.

Bone conduction testing is done by placing an oscillator on the mastoid process

and measuring threshold at the same frequencies.

This test is applicable from the age of six. The duration is 15 minutes.

The test is part of the clinical routine, it may be that children have already

been tested. Children that have not been tested as part of the clinical routine

in the prior six months are required to undergo pure tone audiometry for the

purpose of this study.

This test will serve as one of the measures for the participants* auditory

functioning.



Speech audiometry in quiet

To test speech perception in quiet, the clinically used Dutch speech test of

the Dutch Society of Audiology was used (39), which consists of phonetically

balanced monosyllabics (consonant-vowel-consonant). Stimuli are presented at a

comfortable sound level, corresponding to the range of speech levels that

participants perceive in daily life. Speech perception is measured in the best

aided condition, therefore children wear the hearing devices (cochlear implants

or hearing aids) as they would wear in daily life.

This test is applicable from the age of four. The duration is 15 minutes.

This may be part of the clinical routine, though this must be within 6 months

of the questionnaire answering. If not, then the test or the questionnaires

will be administered within that time limit.

This test will serve as one of the measures for the participants* auditory

functioning.



Speech audiometry applied as Digits in Noise (DIN) test

The DIN is a speech-in-noise test where the listener is requested to return the

spoken numbers (digits) that are offered to them along with audible noise (40).

The prerecorded male-spoken speech-signal consists of three consecutive digits

(from zero to nine). The listener*s echoed triplet is rated correct or

incorrect by an experienced audiometrist. In total, 24 digit triplets are

presented for each DIN test. The speech recognition threshold is defined as the

average of the SNRs and is calculated automatically by the computer. This test

is applicable from the age of three years and six months.

The duration is 6 minutes.

This may be part of the clinical routine, though this must be within 6 months

of the questionnaire answering. If not, then the test or the questionnaires

will be administered within that time limit.

This test will serve as one of the measures for the participants* auditory

functioning.



Emotion expression and recognition in speech



Emotion recognition in speech applied as EmoHI test

The EmoHI test is a recently developed tool to estimate the recognition of

emotion in speech by hearing impaired children (32). During the test,

participants are asked to link images of a depicted emotion to audio clips

containing non-existent words or sentences expressed with a certain emotion.

The test is administered to the children in the otorhinolaryngology department.

On a computer screen, three clowns are depicted, each expressing one of the

three emotions: anger, sadness, happiness. Audio clips with the vocal cues are

accompanied with a visual stimulus of a parrot moving its beak, to indicate

that a cue has been given. Participants are asked to touch or click on the

clown of choice, after which either a video of confetti falling, or the parrot

shaking its head is shown, to indicate a correct or wrong answer. The test has

been validated and normdata is available (32).

The EmoHI test is applicable from the age of four.

The average duration of the test is 7 minutes.

The score on the test will serve as an age-adjusted indicator of the child*s

ability to recognize emotion in speech.



Emotion expression in speech

To estimate the participants* ability to express emotion in speech,

participants will be asked to repeat six sentences and simultaneously express a

requested emotion. The test will be administered in the otorhinolaryngology

section of the hospital. A set of standard sentences will be used. The child is

requested to repeat the sentence while expressing either happiness, sadness, or

anger. The expressed sentence is recorded with a microphone. The recordings are

analysed and scored to the degree of adequately expressed emotion.

The test is applicable from the age of four.

The average duration of the test is 5 minutes.

The score on this test will serve as an indicator of the child*s ability to

express emotion in speech.



Speech/language abilities



Children*s Communication Checklist

The Dutch version of the Children*s Communication Checklist (CCC) will be used

to identify social and pragmatic language abilities indicated by parents or

caregivers (33). This questionnaire (with 70 items divided over eight scales)

has been validated with children aged 4 to 16. A general composite of

communication is conventionally obtained by using the scales Speech production,

Syntax, Semantics, Coherence, Inappropriate initiation, Stereotyped

conversation, Use of context, and Nonverbal communication. A copy of the second

version of the Dutch CCC can be found in appendix 4.

On average, it takes 15 minutes to complete the questionnaire.

The score on this questionnaire will serve as an indicator of the child*s

language abilities.

Secondary study parameters/endpoints

Gender; age; comorbidity; socio-economic status; degree of hearing loss; age of

onset; experience with a hearing device; type of hearing device; modality of

aided hearing; communication mode (sign language/spoken/combination); type of

schooling. Intelligence estimates based upon existing test results from patient

files and school functioning. Speech/language score as estimated with the

CCC-2.