Validation of the LittlEARS® Auditory Questionnaire in children with normal hearing

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Abstract

Objectives

With more children receiving cochlear implants during infancy, there is a need for validated assessments of pre-verbal and early verbal auditory skills. The LittlEARS® Auditory Questionnaire is presented here as the first module of the LittlEARS® test battery. The LittlEARS® Auditory Questionnaire was developed and piloted to assess the auditory behaviour of normal hearing children and hearing impaired children who receive a cochlear implant or hearing aid prior to 24 months of age. This paper presents results from two studies: one validating the LittlEARS® Auditory Questionnaire on children with normal hearing who are German speaking and a second validating the norm curves found after adaptation and administration of the questionnaire to children with normal hearing in 15 different languages.

Methods

Scores from a group of 218 German and Austrian children with normal hearing between 5 days and 24 months of age were used to create a norm curve. The questionnaire was adapted from the German original into English and then 15 other languages to date. Regression curves were found based on parental responses from 3309 normal hearing infants and toddlers. Curves for each language were compared to the original German validation curve.

Results

The results of the first study were a norm curve which reflects the age-dependence of auditory behaviour, reliability and homogeneity as a measure of auditory behaviour, and calculations of expected and critical values as a function of age. Results of the second study show that the regression curves found for all the adapted languages are essentially equal to the German norm curve, as no statistically significant differences were found.

Conclusions

The LittlEARS® Auditory Questionnaire is a valid, language-independent tool for assessing the early auditory behaviour of infants and toddlers with normal hearing. The results of this study suggest that the LittlEARS® Auditory Questionnaire could also be very useful for documenting children's progress with their current amplification, providing evidence of the need for implantation, or highlighting the need for follow-up in other developmental areas.

Introduction

The widespread implementation of newborn hearing screening and subsequent earlier intervention with cochlear implants (CI) has necessitated more and better ways of assessing younger and younger children. With infants as young as 5 or 6 months old receiving a CI, there is a clear need for validated tools assessing auditory–verbal progress after implantation which are sensitive to the particular skill set of the pre-verbal child. Now more than ever, these tools are not only relevant to evidence-based practice in the area of cochlear implantation, but they are crucial to predicting timelines and expected outcomes with the individual in mind. Significant differences have been documented in the auditory–verbal growth of children implanted under the age of 4 versus under the age of 2 [1], [2], [3], [4], [5], [6]. In fact, children implanted before the age of 2 reportedly now have the possibility of closing the gap between their own auditory–verbal skills and that of normal hearing peers [7]. In addition, support for very early implantation and for the existence of a “critical” or at least “sensitive” period for optimal auditory and verbal development [8] is growing and with it, the need for strong and valid measures. Knowing exactly how the skill set of each individual child compares to that of normal hearing peers would be useful in determining realistic goals and targets for therapy, not to mention counselling parents along those lines.

A good measure of auditory skill development must be validated if it is meant to inform evidence-based rehabilitation practice. It must be able to furnish pre-operative, post-operative and follow-up data. The availability of a variety of relevant and appropriate evaluations in several languages is essential for documenting the benefits of early implantation and aiding in the decision-making processes of families of newborns with hearing impairment worldwide.

The MED-EL LittlEARS® Auditory Questionnaire (LEAQ) [9], [10] was designed as a continuation of the Evaluation of Auditory Responses to Speech (EARS) [11], a comprehensive test battery developed in 1996 by Allum-Mecklenburg to aid the evaluation and rehabilitation of CI recipients 3 years and older. The LEAQ was the first LittlEARS® module introduced and supplies a general picture of auditory behaviour and functioning for children under the age of 2. The 35 “yes/no” questions draw from speech-language research documenting the receptive, semantic, and expressive behaviours and milestones which normally constitute an infant or toddler's reactions to auditory stimuli in the natural environment. The LEAQ yields a total score (total of “yes” responses) which corresponds to expected values for a given age. In this way the LEAQ is intended to document general progress and age appropriateness of the auditory behaviours exhibited by the infant or toddler pre-operatively and after cochlear implantation. The LEAQ aims to provide valuable information to clinicians concerned with the progress of infants and toddlers with normal hearing or with infants who need general follow-up after newborn hearing screening [12].

To generate the relevant items for the questionnaire a thorough literature review and focus groups discussions, such as paediatric audiologists, psychologists, statisticians, and speech pathologists, were obtained. Further, the experience and results of existing developmental scales, such as: “Receptive – Expressive Emergent Language Test” [13], “Mac Arthur Communicative Development Inventories” [14], “ELFRA” [15], “The Rossetti Infant and Toddler Language Scale” [16], and “IT-MAIS” [17] were studied before creating the new questionnaire.

Speech and language development research considers the perception of acoustic signals in babies to be one of the crucial aspects of their development. One of the general questions regarding pre-verbal auditory development is how babies behave in response to auditory stimuli? Northern and Downs [18] provide an overview of observable behavioural responses: reflexive, orienting and attentive. Additionally, the head turning behaviour was described as an orienting response with reference to the localization of a sound source. With continuing development, auditory behaviour can also be detected using visual reinforcement and conditional behavioural responses [19]. Infants clearly show preference to their mother's voice and are able to recognise rhymes and melodies as well as to use sentence prosody in order to discriminate words [20], [21], [22]. Newborns also show the ability to discriminate suprasegmental, prosodic features [23], [24] and infants can discriminate phonetic components of a language [24], [25]. Later on, infants are able to distinguish words from other acoustic stimuli and associate them with their conceptual representations [26], [27]. Auditory skills obtained in the pre-verbal stages of development seem to be crucial for the communicative progress and have a significant value in child's further speech and language development.

The questionnaire format relies on parental observation; this format is justified, as infants and toddlers are often unwilling to participate in unfamiliar situations and are too young for standardized testing. According to Grimm and Doil, parent questionnaires have been shown to be “suitable and reliable screening tools with high validity” [15]. The LEAQ was designed with special attention to the quality requirements outlined by Grimm and Doil [15] and with efficiency in mind.

The purpose of the current study was (1) the validation of the LEAQ on children with normal hearing who are German speaking, as published in German by Weichbold et al. [28] and (2) the adaptation and validation of the LEAQ in 15 languages.

Section snippets

Study 1—development of the German version of the LEAQ

The LEAQ was initially developed in German, and both its theoretical background and validation statistics have been reported in German [28]. Because this version was the basis for the English version from which subsequent versions came, a brief report about its construction is given here.

Methods

After validation of the German version of the questionnaire on a sample of 218 children with normal hearing, the LEAQ was adapted into English (see procedure below). From this English version it was and is still being adapted into a number of languages. In each case, validation of the LEAQ in each individual language is encouraged. This paper will report on the validation of LEAQ in 15 languages.

Discussion

The results of this two part study confirm that the LEAQ is a relevant, language-independent tool which may be used internationally for assessing the age-related auditory behaviours of children. The LEAQ has been in use for several years, which implies that clinicians have placed their trust in its results. Though Weichbold et al. [28] were able to provide information on the LEAQ's reliability in a German and Austrian sample, this study provides further results on psychometric measures of the

Acknowledgements

We thank Ms. Robin Cooley who provided medical writing services and Ms. Edda Amann who provided statistical analyses, both on behalf of MED-EL, GmbH.

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