Braz. j. . vol.81 número2

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Auditory

and

language

skills

of

children

using

hearing

aids

夽

Leticia

Macedo

Penna

∗

_,

_Stela

_Maris

_Aguiar

_Lemos,

_Cláudia

_Regina

_Lindgren

_Alves

UniversidadeFederaldeMinasGerais(UFMG),BeloHorizonte,MG,Brazil

Received10November2013;accepted12May2014 Availableonline18October2014

KEYWORDS

Hearingloss; Childlanguage; Hearingaids; Auditoryperception; Correctionofhearing impairment

Abstract

Introduction:Hearinglossmayimpairthedevelopmentofachild.Therehabilitationprocess forindividualswithhearinglossdependsoneffectiveinterventions.

Objective:Todescribethelinguisticprofileandthehearingskillsofchildrenusinghearingaids, tocharacterize therehabilitationprocess andtoanalyze itsassociationwiththe children’s degreeofhearingloss.

Methods:Cross-sectionalstudywithanon-probabilisticsampleof110childrenusinghearing aids(6---10yearsofage)formildtoprofoundhearingloss.Testsoflanguage,speech percep-tion,phonemicdiscrimination,andschoolperformancewereperformed.Theassociationswere verifiedbythefollowingtests:chi-squaredforlineartrendandKruskal---Wallis.

Results:About65%ofthechildrenhadalteredvocabulary,whereas89%and94%hadaltered phonologyandinferiorschoolperformance,respectively.Thedegreeofhearinglosswas asso-ciatedwithdifferencesinthemedianageofdiagnosis;theageatwhichthehearingaidswere adaptedandatwhichspeechtherapywasstarted;andtheperformanceonauditorytestsand thetypeofcommunicationused.

Conclusion:Thediagnosisofhearinglossandtheclinicalinterventionsoccurredlate, contribut-ingtoimpairmentsinauditoryandlanguagedevelopment.

夽

Pleasecitethisarticleas:PennaLM,LemosSM,AlvesCR.Auditoryandlanguageskillsofchildrenusinghearingaids.BrazJ Otorhino-laryngol.2015;81:148---57.

∗_{Corresponding}_author.

E-mail:leticiapenna@hotmail.com(L.M.Penna).

http://dx.doi.org/10.1016/j.bjorl.2014.05.034

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PALAVRAS-CHAVE

Perdaauditiva; Linguageminfantil; Auxiliaresdeaudição; Percepçãoauditiva; Correçãode deficiênciaauditiva

Habilidadeslinguísticaseauditivasdecrianc¸asusuáriasdeaparelhoauditivo

Resumo

Introdução: Adeficiênciaauditivapodecomprometerodesenvolvimentoinfantil.Oprocesso dereabilitaçãodosindivíduoscomperdaauditivadependedeintervençõeseficientes.

Objetivo: DescreveroperfillinguísticoeashabilidadesauditivasdeusuáriosdeAparelhode AmplificaçãoSonoraIndividual(AASI),caracterizaroprocessodeintervençãofonoaudiológica eanalisarsuarelaçãocomograudaperdaauditivadascrianças.

Método: Estudotransversalcomamostranão-probabilísticacompostapor110criançasde6a10 anosdeidade,comperdaauditivadegrauleveaprofundo,usuáriasdeAASI.Foramrealizados testes de linguagem,percepção de fala, discriminação fonêmica e desempenho escolar.As associaçõesforamverificadaspelostestes␹2detendêncialineareKruskal-Wallis.

Resultados: Cercade65%dascriançasapresentavamalteraçãodovocabulário,89%defonologia e94%tiveramdesempenhoescolarconsideradoinferior.Ograudaperdaauditivamostrou-se associadoadiferençasnasmedianasdasidadesdediagnóstico,deadaptaçãodoAASIedeinício dafonoterapia;dotempoentrediagnósticoeadaptaçãodoaparelhoauditivo;aoresultadodos testesauditivoseaotipodecomunicaçãoutilizada.

Conclusão:Independentemente dograu de perdaauditiva, odiagnóstico e as intervenc¸ões necessáriasocorreramtardiamente,comprejuízodashabilidadeslinguísticaseauditivasdestas crianc¸as.

Introduction

Hearinglossisahigh-prevalencedisease,rangingfromone tothreeper1000individuals;thisnumberincreasesinthe presenceofriskfactorsforhearingimpairment.1,2_Its_main consequence, especiallyin children, is theimpactcaused bysensorydeprivationinthedevelopmentofauditoryand languageskillsandlearning.Anydegreeofhearinglosscan resultinsignificantdamage,asitinterfereswithperception andunderstandingofspeechsounds.3

Inthenationalscenario,duetothesocialmagnitudeof hearingimpairmentprevalenceanditsconsequencesinthe Brazilianpopulation,theMinistryofHealth4,5_instituted_the HearingHealthCareServices(Servic¸osdeAtenc¸ãoàSaúde Auditiva ---SASA)which,togetherwiththeNeonatal Hear-ingScreeningProgram, haveasagoaltheearlydiagnosis, intervention,andrehabilitationofindividualswithhearing impairment.

The first years of life areconsidered critical for child development,as the peakof the central auditory system maturation process occurs during childhood and neuronal plasticityisat itsmaximum.6_This _makes_the_early detec-tionofhearingimpairmentcrucialtominimizethedamaging impactonthedevelopmentoflanguageandlisteningskills, aswellasonthelearningprocesscausedbyhearingloss.6---11 In addition to an early diagnosis, the literature also points out the importance of interventional speech ther-apyinthesuccessfulrehabilitationofchildrenwithhearing impairment.6,7_The_earlier_the_diagnosis _is_established_and auditory speech therapy is initiated, the closer develop-mentofaffectedchildrenwillbetothatofnormalhearing children.9,11

Thus,thisstudyaimedtodescribetheoral andwritten linguistic profile and auditory skills of children using an

individualsound amplification device (ISAD), fitted in the period2008---2010inaSASA,andtocharacterizetheprocess ofspeechtherapy interventionandanalyzeitsassociation withthedegreeofhearinglossofthechildren.

Methods

This wasa cross-sectional,observational study conducted inahigh-complexitySASAinBeloHorizonte,stateofMinas Gerais,Brazil,fromSeptemberof2011toMayof2012.

After data collectionfrom the service’s database, 206 childrentreatedintheyears2008---2010,whohadan audi-tory diagnosis confirmed through pure tone and speech audiometryassessment,wereidentified.

Exclusion criteria included normal hearing, history of otorhinolaryngological surgery, treatment abandonment, transfertoanotherSASA,presenceofsyndromesand asso-ciated neurological alterations, and death; the eligible populationconsistedof131children.Ofthese,sevencould notbelocatedand14didnotattendtheevaluation.Thus, thepopulationconsistedof110individuals.

All110childrenwereassessedindividuallyfor language and auditory skills, and during the evaluation they used theISAD.Theevaluationwasperformedinasinglesession lastingan averageof1h.Parentsorguardiansanswereda structuredquestionnaireaimedtocharacterizethesample, withthefollowing thematicaxes:riskindicators for hear-ingloss at birth, dataon auditory diagnosis, intervention andspeechtherapy/audiologicalfollow-up,schoollife,and socioeconomicindicators.

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vocabulary,fluency,andpragmatics.Thisresearchusedthe phonologyandvocabularytasks.Onlyorallycommunicative children(n=80)wereabletoperformthesetests.

Forthevocabularytest, therecordingofthechildren’s responses immediately followed thenaming, inindividual sheets,andthecriteriaestablishedbythetestauthorwere followedfortheanalysis.13,14

Forthephonologyassessment,thisstudyusedthe sponta-neousnamingtask.Therecordingofresponseswascarried outwitha Cassio® _Exilim_digital _camera, _in _movie _mode. Afterlistening tothe file, the phonetic transcription and analysisofresponseswereperformed.Therecordingofone childwithmoderatelyseveretoseverehearinglossdegree couldnotberecovered.Thecriteriaestablishedbythetest authorwerefollowedfortheanalysis.15

TheSchoolPerformanceTest(SPT)wasusedtoevaluate thewritten language16_;_it_was_developed_for_evaluation_of schoolchildrenfromthefirsttothesixthgradeofelementary school.Itconsistsofthreesubtests:writing,arithmetic,and reading.ThefinalclassificationoftheSPTandofeach sub-testwasperformedasdescribedbytheauthorofthetool.17 Toanalyzetheresults ofSPTtest inthe firstgraders,the middle-lowerandmiddle-upperclassificationsweregrouped inthe‘‘medium’’category.

Twoprotocolswereusedtoevaluatehearingskills:the GlendonaldAuditoryScreeningProcedure(GASP)18 _and_the phonemediscriminationtestwithfigures.19_The_speech per-ceptiontest --- GASP --- consists of fivetests thatevaluate thecapacityofdetectingLingsounds,voweldiscrimination, extension discrimination, word recognition, and compre-hensionofsentencesusingtheISAD.The testanalysiswas performed assuggested by the literature.18 _This _research also evaluated the overall test result by calculating the meansofalltestsinordertoanalyzetheoverallresultand compareindividuals.

Thephonemediscriminationtestwithfiguresassessesthe phonemic discrimination capacity through minimal pairs. The final score was classified as adequate or altered according to age, following the criteria proposed by the literature.19_A_zero_score_was_considered_for_those_children whowereunabletoperformthetest.

The analysis of the child’stype of communication was dividedintothreecategories:orallycommunicative,orally communicativeassociatedwiththeBrazilianSignLanguage (LínguaBrasileiradeSinais[LIBRAS];thechildcanexpress herselforally,butusesLIBRASwhenhe/shecannot commu-nicateeffectively), andnon-orallycommunicative(LIBRAS user exclusivelyand/or functional gestures), according to theanswergivenbytheparent/guardianonthe question-naire.

Theauditorydiagnosiswasmadeaccordingtothe crite-riaestablishedintheliteratureregardingdegreeandtype.20 Toanalyzethevariabledegreeofhearingloss,the diagno-sisinthebetterearwasconsideredandthechildrenwere divided into threegroups: mild tomoderate; moderately severetosevere,andprofoundbilateralhearingloss.This studyobservedchildrenwithsensorineural,conductive,and mixedhearinglossinallthreegroups.

Datawere storedin electronicfiles, withdoubleentry andcheckingoftheconsistencyofthedatabase.The statis-ticalpackageEpiInfo7.1.0.6wasusedfordataprocessing andanalysis.

Descriptive analysis of the frequency distribution of categorical variables and analysis of measures of central tendency anddispersionfor continuousvariableswas per-formed. The Kruskal---Wallis test was used to verify the association between the degree of hearing loss and the aspects of speech therapy intervention and auditory per-formanceintests.Thelevelofsignificancewassetat5%.

The chi-squared test for linear trend wasusedto ver-ifytheassociationbetweenthedegreeofhearinglossand thetypeof communicationused,comparingchildrenwith mild/moderatehearinglosstotheotherswithmore signifi-canthearingloss.

ThisstudywasapprovedbytheResearchEthics Commit-teeofUniversidadeFederaldeMinasGerais,underOpinion No.ETIC0316.0.203.000-10.Allparentsorguardiansofthe childrenparticipatinginthestudysignedtheinformed con-sent(IC).

Results

The main characteristics of the 110 childrenevaluated in thisstudyaredescribedinTable1.

Thedegreeofhearinglosswasmostfrequently moder-atelysevere/severe(43.7%).Themostfrequentaudiometric curve was downward sloping (56.3% in the RE and 53.6% in the LE). The median timeof hearing aid fitting of the childrenwas2.68years(range0.9---4.5years).

Table 2 describes aspects of the audiological/speech therapyintervention.

Therewasastatisticallysignificantdifferencebetween themedianagesatdiagnosis,ageathearingaidfitting,time betweendiagnosisandhearingaidfitting,andtheinitiation ofspeechtherapyaccordingtothedegreeofhearingloss.

Therewasno association between follow-upin speech therapy,thenumberofspeechtherapyconsultations, con-tinuity of the speech therapy process, and the type of institutionthechildrenattendedforspeechtherapy accord-ingtothedegreeofhearingloss.

Thedistributionofthechildrenaccordingtothedegree ofhearinglossandthetypeofcommunicationused,andthe resultsoftheorallanguageandwritingtestsareshown in

Table3.

Regardinglanguage,65%ofthechildrenhadbelow nor-mal vocabulary and 88.8% had some abnormalities in the areaofphonology.

Table4showstheresultoftheassociationbetweenthe degreeofhearinglossandthetypeofcommunicationused bythechildrenwithhearingimpairment.

Therewasan association between thedegree of hear-inglossandthetypeofcommunicationusedbythechild. Theriskthatachildwithmoderatelysevere/severedegree of hearing loss would not use oral language to communi-catewas6.2timeshigherthanachildwithmild/moderate degreeofhearingloss;andtheriskofachildwithprofound bilateralhearinglossofnotusingorallanguageto communi-catewas83.1timeshigherthanachildwithmild/moderate degreeofhearingloss.

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Table1 Generalcharacteristicsoftheassessedchildren andtheirfamilies.

Characteristic n %

Child’sgender

Female 42 38.2

Male 68 61.8

Child’sage

Mean±SD:8.5±1.5years 24 21.8 Median:8.5years 19 17.2 6years---7years 22 20.0 7years---8years 18 16.3 8years---9years 27 24.5 9years---10years

10years---11years

Typeofschool

Regularschool 92 83.6

Special-needsschool 18 16.4

Ageatschoolenrollment

Upto6years 100 90.9

After6years 6 5.4

Nodata 4 3.7

Appropriateagefortheschoolyear

Yes 41 37.3

No 69 62.7

TDEresult

Inferior 103 93.6

Medium 5 4.5

Superior 2 1.9

Maternalyearsofschooling

Mean±SD:7.8±3.4years/median8years 1 0.9

Illiterate 28 25.4

1---4yearsofschooling 30 27.2 5---8yearsofschooling 45 41.1 9---11yearsofschooling 3 2.7 Morethan11yearsofschooling

Noinformation

Percapitaincome

Upto1minimumwage 95 86.3 >1minimumwage 12 10.9

Noinformation 3 2.8

Presenceofriskindicatorforhearingloss

Yes 44 40

No 66 60

Degreeofhearingloss

Profoundbilateral 25 22.7 Moderatelysevere/severe 48 43.7

Mild/moderate 37 33.6

Typeofhearinglossintherightear

Sensorineural 104 94.5

Mixed 2 1.8

Conductive 3 2.8

Normalhearing 1 0.9

Table1(Continued)

Characteristic n %

Typeofhearinglossintheleftear

Sensorineural 104 94.5

Mixed 2 1.8

Conductive 3 2.8

Normalhearing 1 0.9

TimeofuseofISAD/day

Upto4h/day 14 12.7

From5to8h/day 37 33.7 Morethan8h/day 59 53.6

Discussion

Themean ageof thechildrenevaluatedin thisstudy was eightyearsandsixmonths;mostofthemattendedregular schoolandhadstartedschoolbeforeage6.Atthisage,the childisexpectedtobewell-adaptedatschoolandtohave acquiredanextensivevocabulary,toknowtherulesof syn-tax,andtohaveacquiredallspeechsounds.7,13,21_However, most of the study children did not achieve the expected resultsinthephonologyandvocabularytest,regardlessof thedegreeofhearingloss.

The assessed children showed a prevalence of moder-atelysevere/severehearingloss,withadownwardsloping audiometriccurve.Thistypeofconfigurationcanresultin greatdeficitsin receptive andexpressive language, espe-ciallyin discrimination and recognition of speechsounds, particularlyfricativesounds.17,22

Regardingthetypeofhearingloss,thesensorineuraltype wasthemostoftenobservedinthisstudy.However,insome children,differenttypesofhearinglosswerefoundineach ear.In the sensorineural type, hearing loss is most often irreversibleandthegreaterinvolvementoccursatthelevel ofauditorycomprehension.23 _In_the_conductive_and_mixed types, hearing fluctuation may hinder speech intelligibil-ity,and consequently, the child can develop phonological and auditory processing alterations, as well as learning difficulties.22

Inthegroupofchildrenwithprofoundbilateralhearing loss,theageattheauditorydiagnosis andtheageatISAD fitting were lower than in the other studied groups. This canbeexplainedbythefactthatprofound hearinglossis moreeasilyperceivedbythefamilyandhealthprofessionals involvedwiththechild.24_Early_referral_favors_the_process_of diagnosisandthefittingoftheISADinatimelyandefficient manner.However,incasesofless severehearingloss,the child’sdifficultiescangoundetectedbyhealthprofessionals andthefamily,andareoftenobserved byteachersduring theemergenceoflearningdisabilities.6,23

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Table2 Aspectsofspeechtherapyinterventionaccordingtothedegreeofhearingloss. Degreeofhearingloss

Speechtherapy/audiologyintervention Profoundbilateral (n=25)

Moderately

severe/severe(n=48)

Mild/moderate (n=37)

p-Value

Ageatdiagnosis

Amplitude(years) 0.5---6.5 0.98---8.3 0.7---9.0 <0.001a

Median(years) 3.3 5.0 5.6 0.009a

AgeatISADadaptation

Amplitude(years) 2.6---7.6 2.0---9.1 2.0---9.3

Median(years) 4.9 5.5 6.8

TimebetweendiagnosisandISADadaptation

Amplitude(years) 0.1---4.2 0.1---3.5 0---7.5 0.04a

Median(years) 1.4 0.7 0.5

Weeklyindividualspeechtherapysessions

Amplitude(years) 1---8 1---8 2---9 0.09b

Median(years) 3 4.5 5

Speechtherapyfollow-up

Yes 21 43 32 0.49b

No 4 5 5

Institutionwherespeechtherapywascarriedoutc

Public 13 33 23 2.33b

Private/others 8 10 9

Speechtherapyprocessc

Continuous 13 24 15 0.42b

Discontinuous 8 19 17

Frequencyofspeechtherapyc

≥2times/week 20 41 28 0.26b

<2times/week 1 2 4

a_Teste_{Kruskal-Wallis.}

b _Teste_Qui_Quadrado.

c _Apenas_as_crianc_¸as_que_realizam_fonoterapia.

numberofaudiologicaltestsrequiredforcompletionof diag-nosisinthesechildren.24

Inthisstudy,regardlessofthedegreeofhearingloss,age atdiagnosisandISADfittingoccurredlate,whichis in dis-agreementwithwhatisproposedintheliterature,i.e.,that theauditorydiagnosisshouldbeestablishedbeforethethird monthoflifeandspeechtherapyinterventionbestartedby 6monthsofage.1,22,25

Some studies carried out in Brazil also showed that it wasdifficulttoachieve therecommendedstandards. Ina studythatassessedthestatusofthediagnosisandcareof patients withhearing loss aged 0---14 years in the city of Campinas,themeanageatdiagnosiswas4.3yearsandthe meanageatISAD fittingwas7.5years.24_In_the_study_that aimedtocharacterizetheageatdiagnosisandintervention ofchildrentreatedattheHospitaldasClínicasdeSãoPaulo, themeanageat thesestepswas5.4yearsand6.8 years, respectively.6

Theseaspectsoflanguageinterventionbecomerelevant becausetheageatdiagnosisandadaptationaredetermining factorsfortheprognosisofauditoryandlanguageskill devel-opmentinchildrenwithhearingimpairment.6_The_Newborn HearingScreeningProgram(NHSP)wasimplementedinthe

state of Minas Gerais through SES Resolution No. 1.32126 and became mandatory nationwide through Federal Law No.12.30327 _for_early_detection_of_hearing_loss,_due_to_the impact that hearing loss can have on child development. It is worth mentioning thatthe children evaluatedin this studywerenotsubmittedtotheNHSP,whichmayexplain theresultsrelatedtospeechtherapyintervention.

Regardless of the degree of hearing loss, the effec-tive use of the electronic device alone most often is not enough to minimize the damageto the auditory and lan-guageskills,andspeechtherapyisofutmostimportancein thisprocess.21,28_According_to_the_literature,_the_therapeutic processshouldbestartedasearlyaspossible,becontinuous, andinvolvethechild’sfamily.3

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Table3 Distributionofchildrenaccordingtothedegreeofhearinglossandthetypeofcommunicationused,andresultsof oralandwrittenlanguagetests.

Degreeofhearingloss

Communicativeprofile Profoundbilateral (n=25)

Moderatelysevere/ severe(n=48)

Total

n % n % n % n %

Communication

Oral 3.0 12.0 31.0 64.6 34.0 91.9 68.0 61.8

Oral+LIBRAS 1.0 4.0 9.0 16.7 3.0 8.1 12.0 10.9

Non-oral 21.0 84.0 8.0 18.8 0.0 0.0 30.0 27.3

Vocabularyalterationa

General 3.0 100.0 31.0 77.5 18.0 48.6 52.0 65.0

Clothing 3.0 100.0 31.0 77.5 22.0 59.5 56.0 70.0

Animals 1.0 33.3 12.0 30.0 5.0 13.5 18.0 22.5

Food 3.0 100.0 40.0 100.0 29.0 78.4 72.0 90.0

Transportation 2.0 66.6 17.0 42.5 9.0 24.3 28.0 35.0

Furnitureandutensils 2.0 66.6 18.0 45.0 8.0 21.6 28.0 35.0

Professions 3.0 100.0 32.0 80.0 15.0 40.5 50.0 62.5

Places 3.0 100.0 39.0 97.5 31.0 83.8 73.0 91.2

Shapesandcolors 2.0 66.6 26.0 65.0 16.0 43.2 44.0 55.0

Toysb _2.0 _66.6 _27.0 _67.5 _19.0 _51.4 _48.0 _60.0

Alterationofphonologya

Presenceofalteration 3.0 100.0 38.0 42.6 31.0 83.8 72.0 88.8

Presenceofomission 2.0 66.6 20.0 48.7 14.0 37.8 36.0 44.4

Presenceofsubstitution 3.0 100.0 34.0 82.9 24.0 64.8 61.0 75.3

Presenceofdistortion 2.0 66.6 16.0 39.0 9.0 24.3 27.0 33.3

Presenceofculturalpattern 3.0 100.0 32.0 78.0 25.0 67.5 60.0 74.0

PerformanceatSPT

General

Inferior 25.0 100.0 47.0 97.9 31.0 83.8 103.0 93.6

Medium 0.0 0.0 1.0 2.1 4.0 10.8 5.0 4.5

Superior 0.0 0.0 0.0 0.0 2.0 5.4 2.0 1.8

Reading

Inferior 25.0 100.0 44.0 91.7 24.0 64.9 93.0 84.5

Medium 0.0 0.0 4.0 8.4 11.0 29.7 15.0 13.7

Superior 0.0 0.0 0.0 0.0 2.0 5.4 2.0 1.8

Writing

Inferior 25.0 100.0 47.0 97.9 29.0 78.4 101.0 91.8

Medium 0.0 0.0 1.0 2.1 7.0 18.9 8.0 7.3

Superior 0.0 0.0 0.0 0.0 1.0 2.7 1.0 0.9

Arithmetic

Inferior 25.0 100.0 46.0 95.9 27.0 73.0 98.0 89.1

Medium 0.0 0.0 2.0 4.2 8.0 21.6 10.0 9.0

Superior 0.0 0.0 0.0 0.0 2.0 5.4 2.0 1.8

LIBRAS,BrazilianSignLanguage;SPT,schoolperformancetest.

a _Only_orally_{communicative}_children.

b _Toys_and_musical_instruments.

therapy was by the Brazilian Unified Health System (Sis-temaÚnicodeSaúde[SUS])30_and_another_that_investigated the characteristics of diagnosis andspeech therapy inter-ventioninchildren withhearingimpairmentin thecityof Blumenau.31

The largenumberofchildrenwithbelownormal devel-opment of oral and written language and listening skills, regardless of the degree of hearing loss, reflects the

consequencesofspeechtherapyinterventionforthese indi-viduals.

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Table4 Association between the degree of hearing loss and the type of communication used by children with hearing impairment.

Communicationuseda

Degreeofhearingloss Oral Others OR 95%CI

Mild/moderate 34 3 1

Moderatelysevere/severe 31 17 6.2 1.50---29.70

Profoundbilateral 3 22 83.1 12.67---731.15

a_Teste_Qui_Quadrado_de_Tendência.

an ISAD and undergoingspeechtherapy intervention,will have development close to that of children with normal hearing.17

Moderatelysevere/severehearinglosscanhaveagreater impactonthedevelopmentofauditoryandlanguageskillsin childrenwithhearingimpairmentwhencomparedtothose withmild/moderatehearingloss.However,theuseof hear-ing aids and the stimulation of the auditory skills would allowthesechildrenasatisfactoryhearingandorallanguage development.

Inthisstudy,alargenumberofchildrenhadsignificant difficultyinlisteningcomprehensionskills.Asaresult,many arenot orally communicative, and amongthose who use speechtocommunicate,mostofthemshowedgreatdelay inlexicalandphonologicaldevelopment.

Forthegroupofchildrenwithprofoundbilateralhearing loss,noresponsewasobserved tothedetection, discrim-ination,perceptionofextension,recognitionandlistening comprehensionskills.Fewchildreninthisgroupusedspeech tocommunicate, and those whowere orally communica-tiveshowedasignificant delayinlexicalandphonological development.Theresidualhearingobservedinchildrenwith profound bilateral hearing loss is small, which limits the dynamicrangeof hearingand, consequently,theauditory gainwiththeISAD,explainingthegreatdifficultythese chil-drenexperienceintheperceptionofenvironmentalsounds andspeech.32,33

In these cases, the use of the cochlear implant is indicated;ithasprovidedgreatbenefitsinlanguage devel-opmentinchildrenwithprofoundhearingloss,asitprovides accesstospeechinformation,particularlyathigh frequen-cies,whichisgenerallynotpossiblewiththeuseofanISAD. Moreover,implanted children have better speech percep-tion,increasednumberofproducedvowelsandconsonants, and better speech intelligibility than those using hearing aids.28,32,33

However,forthistypeof interventiontobeperformed withsatisfactoryoutcomesinthedevelopmentofauditory andlanguageskills,thehearingdiagnosisandspeech ther-apyinterventionmustbeearly.28,34

Regardingtheperformanceofwrittenlanguageskillsin allevaluatedgroups,themajorityofthechildrenhadalow performanceintheacademicachievementtest.Thisresult maybeassociatedwithlowperformanceintheauditoryand orallanguagetests.Itiscommontoobservelearning diffi-cultiesinchildrenwithhearingimpairment,asthedeficitsof orallanguageandauditoryskillscanhave,asaconsequence, changesinthedevelopmentprocessofreading,writing,and logicalandmathematicalreasoning.

Moreover, the domains of capacity of symbolization, generalization, manipulation of sounds, and phonological awarenessarealsocrucialinlearningandarepoorly devel-opedinthesechildren.35

Thehearingandlanguageimpairmentsobservedinthese twogroupscouldhavebeenminimizedifthesechildrenhad beenassessedbytheNHSPandspeechtherapyintervention hadbeeninitiatedearly.Thecriticalperiodofcentral audi-torysystemmaturationmainlyoccursinthefirstfiveyearsof life.34_However,_the_age_at_diagnosis,_ISAD_fitting,_and_start ofspeechtherapyfoundforthesegroupswereaftertheage of5years.Additionally,socioeconomicfactorscanalso influ-encechildren’sdevelopment.3,36 _In_this_study,_most_of_the childrencamefromfamilieswithpercapitaincomebelow theminimumwageandthelevelofparentaleducationwas low.

Thedifficultyintheauditoryskills oftheassessed chil-dren,regardlessofthedegreeofhearingloss,canalsobe seeninthediscrepancybetweentheresultsofthetwo hear-ingtests.Inallgroups,thebetterresultswereobservedin theGASPtestthaninthephonemediscriminationtestwith figures.Thisfactcanbeexplainedbythedifferentauditory skillsrequiredineachtest.Theskillsofdetection,vowel dis-crimination,perception ofextension,auditory recognition inaclosed set,andcomprehensionofeverydaysentences areinvolvedtheGASPtestperformance.

Asforthephonemediscriminationtestwithfigures,the auditory skill involved is phonemic discriminationof min-imal pairs. For the child to have a good performance in this test, other auditory skills should also be mastered, suchastemporalprocessing.19 _Furthermore,_the _semantic andphonologicalcomponents,phonologicalawareness,and memoryinvolvedincreasethedegreeofthetestdifficulty forchildrenwithhearingimpairment.19

Difficultiesinauditorydevelopment,aswellasoraland writtenlanguageobservedinthesubjectsofthisstudy rein-force the importance of attention and care for children diagnosed with hearing impairment. After the implemen-tation of the National Hearing CarePolicy in 2004 by the Ministryof Health,4,5 _these_individuals_now_have _access_to fullcare,fromtheauditorydiagnosis,provisionofelectronic sound amplification devices (hearing aids and cochlear implants),aswellasspeechtherapy.

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Table5 Performanceoftheeligiblepopulationinthehearing,GASP,andTFDFtests,accordingtothedegreeofhearingloss. Degreeofhearingloss

Hearingdiagnosis Profoundbilateral (n=25)

Moderatelysevere/ severe(n=48)

p-Value

(Kruskal---Wallistest)

GASP/detection

Firstquartile(%) 0---0 36---83 70---100

p<0.001 Secondquartile(%) 0---43 83---98 100---100

Median(%) 43 98 100

Thirdquartile(%) 43---86 98---100 100---100 Fourthquartile(%) 86---100 100---100 100---100

GASP/discrimination

Firstquartile(%) 0---0 0---100 93---100

Median(%) 13 100 100

GASP/extension

Firstquartile(%) 0---0 0---100 0---100

Median(%) 0 100 100

GASP/recognition

Firstquartile(%) 0---0 0---75 91---100

Median(%) 0 100 100

GASP/comprehension

Firstquartile(%) 0---0 0---35 0---90

Median(%) 0 0 100

Thirdquartile(%) 0---0 90---100 100---100 Forthquartile(%) 0---70 100---100 100---100

GASP/general

Firstquartile(%) 0---0 9.2---80.1 66.8---96.6

p<0.001 Secondquartile(%) 0---11.2 80.1---94.3 96.6---100

Median(%) 11.2 94.3 100

Thirdquartile(%) 11.2---32.4 94.3---100 100---100 Fourthquartile(%) 32.4---86 100---100 100---100

TFDF/general

Firstquartile(points) 0---0 0---2.5 0---19

p<0.001 Secondquartile(points) 0---0 2.5---16.5 19---29

Median(points) 0 16.5 29

Thirdquartile(points) 0---0 16.5---28.5 29---35 Fourthquartile(points) 0---27 28.5---36 35---38

GASP,GlendonaldAuditoryScreeningProcedure;TFDF,phonemediscriminationtestwithfigures.

asthetrainingofhealthprofessionalsregardingthe suspi-cionanddiagnosisofhearinglossinchildren,structuringof the newborn hearingscreening program, and investments toqualify the SASAs andrehabilitation centers.Agile and efficientaccessofchildrentoahearinghealthprogramand the availabilityof experiencedand qualified professionals toperformsuchfunctionsshouldbeguaranteed.

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Currently,theassessmentofthehearinghealth service qualityisdirectedtowardinfrastructure(physicalfacilities, number of professionals, equipment) and monthly proce-dureproductivity,whichdoesnotguaranteetheassessment of the quality of services provided. The periodic and standardized assessment of the auditory skills and lan-guage development in children followed in SASAs must be systematically conducted, aiding treatment planning as a resource to assess the quality of the interven-tion.

Thus, longitudinal studies are needed to monitor the qualityof servicesandtheadvancesof thenational hear-inghealthprogramproposals.Theinfluenceofsomefactors suchasage,rehabilitationfacilities,family,socio-economic environment,andthechild’ssocialbehaviorshouldalsobe investigatedinordertoimplementmoreappropriateactions inthedifferentloco-regionalrealities.

Duringthestudyperformance,therewassomedifficulty intheselection ofstandardizedandvalidatedtools devel-opedin Brazilfor children withhearing impairmentolder than6 yearsofage, especiallyfor theassessment of oral language(vocabularyandphonology)andlearning.Inmost cases, in the available assessments, normal values were basedontheperformanceofchildrenwithnormalhearing and,astheprocessesofhearingandlanguagedevelopment ofchildrenwithhearinglossdonotfollowthesame stan-dards,therewassomedifficultywhencomparingwiththe resultsofotherstudies.

Regardingthedevelopmentofphonologyinchildrenwith hearingloss,veryoften thealterationobservedwas asso-ciatedwiththedifficulty inperception anddiscrimination ofspeechsoundscaused bytheauditoryacuityreduction. However,itwasdecidedtoevaluatethisaspectoflanguage developmentwiththe aim of investigatingthe exchanges andphonologicalprocessesobservedinthedevelopmentof theassessedchildren.

ItisnoteworthythattheeffectiveuseofISADs,timeof hearingaidfitting,andthetimeofspeechandaudiological therapymayalsoinfluenceauditorydevelopment,aswellas oralandwrittenlanguage.Inthisstudy,mostoftheassessed childreneffectivelyusedhearingaids.However,therewas alargevariabilityintimeofISADfittingandspeechtherapy amongtheindividuals.

Thesevariablesmayhaveinfluencedthedevelopmentof theassessedchildren,aswellastheirperformanceinthe tests.

Conclusion

Manyofthechildrenwithhearingimpairmenthadabnormal developmentofauditory skills,orallanguage,andwritten language.Thisoutcomeisrelatedtothecharacteristicsof speechtherapy,astheauditorydiagnosis,thefittingofthe ISAD,andspeechtherapy follow-upoccurredlate, regard-lessofthedegreeofhearingloss.

Evaluation of oral and written language and auditory skills of children with hearing impairment shouldbe per-formedperiodically,sothattheprocessofspeechtherapy interventionmaybereassessedandsothetherapeutic strat-egy is planned in accordance with the evolution of each individual.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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