International Journal of Pediatric Otorhinolaryngology
Validation of the LittlEARS® Auditory Questionnaire in children with normal hearing
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.
References (33)
Cochlear implantation in children under the age of two years: candidacy considerations
Otolaryngol. Head Neck Surg.
(1997)- et al.
Does sentential prosody help infants to organize and remember speech information?
Cognition
(1994) - et al.
Development of Language and Speech perception in congenitally, profoundly deaf children as a function of age at cochlear implantation
Audiol. Neurootol.
(2004) - et al.
Cochlear implantation in children under the age of two—what do the outcomes show us?
Int. J. Pediatr. Otorhinolaryngol.
(2003) - et al.
Effects of age at implantation in young children
Ann. Otol. Rhinol. Laryngol.
(2002) - et al.
Cochlear implant candidacy and performance trends in children
Ann. Otol. Rhinol. Laryngol.
(2002) - et al.
Early cochlear implantation in children allows normal development of central auditory pathways
Ann. Otol. Rhinol. Larnygol.
(2002) - et al.
Age at implantation: its importance in pediatric cochlear implantation
Laryngoscope
(1999) - et al.
The effect of age of cochlear implant initial stimulation on expressive language growth in infants and toddlers
J. Speech Lang. Hear. Res.
(2005) - et al.
LittlEARS Auditory Questionnaire
(2004)
Evaluation of Auditory Responses to Speech (EARS)
Receptive–Expressive Emergent Language Test. A Method of Assessing the Language Skills of Infants
Mac Arthur Communicative Development Inventories
ELFRA 1 und ELFRA 2: Elternfragebogen fuer die Frueherkennung von Risikokindern
Cited by (105)
Early cochlear implantation for children with single sided deafness
2024, International Journal of Pediatric OtorhinolaryngologyCochlear implantation and audiological findings in a child with Zellweger spectrum disorder
2023, Otolaryngology Case ReportsValidation of LittleEARS questionnaire in Hindi language
2023, Journal of OtologyComprehensive Audiological Management of Hearing Loss in Children, Including Mild and Unilateral Hearing Loss
2021, Otolaryngologic Clinics of North AmericaCochlear Implant Single-Unit Audio Processors in Young Children
2023, Journal of International Advanced OtologyMMP-9 plasma level as biomarker of cochlear implantation outcome in cohort study of deaf children
2023, European Archives of Oto-Rhino-Laryngology