An Interview with Dana Suskind, MD

The Marion Downs Lecture in Pediatric Audiology is one of the highlights of the annual American Academy of Audiology (AAA) Conference. The 2018 conference in Nashville, Tennessee, will feature Dana Suskind, MD, as the presenter for this year’s lecture on the morning of Friday, April 20. 

Dr. Suskind is a professor of surgery at the University of Chicago and director of the Pediatric Cochlear Implant Program at University of Chicago Medicine Comer Children’s Hospital. She is also the founder and director of Thirty Million Words™ (TMW). Rooted in scientific research focused on the importance of early language exposure and the developing child, TMW assists parents and caregivers in enhancing the home language environment to optimize their children’s brain development. This has downstream impact enhancing a child’s ability to learn, and long-term impact on behavior and self-regulation. This program is for all children, though children with hearing loss can be particularly vulnerable to the 30-million-word gap if early intervention is not provided. 

Dr. Suskind’s work relies on many health-care disciplines to interface with families. The audiologist plays an important role in this network with universal newborn hearing screening. Early intervention means that the audiologist may be one of the first points of contact as parents enter the health-care arena and learn their vital role in the development of their young children. 

I had the pleasure of interviewing Dr. Suskind, and discussing TMW and how the audiologist fits into this program. This discussion provides a preview of what is sure to be an engaging presentation at the AAA Annual Conference 2018.

Brenna Carroll (BC): Thank you, Dr. Suskind, for accepting the Foundation’s invitation to speak at the conference this year. It sounds like you are in the middle of clinic; thanks for taking the time to squeeze me in! The Marion Downs Lecture is one of the highlights of the conference.

Dana Suskind (DS): Thank you for speaking with me. We are all busy, aren’t we? 

BC: I am curious… how did your background evolve from pediatric cochlear implant surgeon to include Thirty Million Words?

DS: I am a cochlear implant surgeon who became an accidental social scientist and it’s been an amazing ride! It began with me starting the pediatric cochlear implant program at the University of Chicago about 10 years ago. I started implanting kiddos and noticed profound outcome differences on children post implantation that looked like they should have been compared. 

Some children would be talking and learning on par with their hearing peers while others would have much more difficulty communicating. I tried to figure out why this was and what I could do about it. I then started to educate myself about childhood development and learned that one of the critical factors of childhood development is early language exposure from birth to age three in his or her environment. A cochlear implant can bring sounds to a child’s brain, but there really is more needed for language development. And the role of the parent is really vital to the child and child’s brain development. 

BC: For those unfamiliar with the term, what is the 30-million-word gap?

DS: The 30-million-word gap can either be a concrete or metaphorical term. There was a famous study done about 30 years ago by researchers Betty Hart and Todd Risley that explored the early experiences of children around language. What they discovered is that children from poorer homes will have exposure to 30 million fewer words by their fourth birthday than their more affluent peers. But what is really important to consider is that this is a small part of what they found. 

They also discovered that there is a huge disparity in the quality of the language exposure. Children from poorer homes experience verbal prohibition, hear less affirmation, less verbal back and forth, and less complex verbal vocabulary. And all of this is termed the “30-million-word gap.” What they also discovered is that this impacts not only vocabulary, but also IQ and test scores in the third grade. The important thing to emphasize is that at first glance it all appears to be about socioeconomic status, but careful analysis really honed it down to language. It is metaphorical as well, because it also highlights the power of parent talk and parent interaction. The downstream impact of the power of the parent includes literacy, math and spatial ability, grit, perseverance, and emotional development. Parent interactions are the building blocks of children’s brains. 

BC: When you look at children with hearing loss from homes with a lower socioeconomic status, are you finding that the gap is even greater? 

DS: Well, that is exactly why early intervention is so critical. What is interesting is that when looking at children with hearing loss prior to the advent of cochlear implantation, language skills were comparable across socioeconomic groups and sign language was the primary mode of language. But the advent of cochlear implantation ushered in a golden age for children with hearing loss. That language gap disappears for children who are identified and receive early intervention. The earlier the intervention occurs, the better.

BC: The TMW initiative mentions the 3Ts. Can you tell us what the 3Ts are?

DS: At the core of all of our programs are two things. One is the idea that babies aren’t born smart, they are made smart. They are made smart by parent/child interaction. It is a fundamental idea because it isn’t just about talk; it is about the idea that when parents invest in a certain way, they build not only the relationship but also the brain. So, it is really about getting the parents to buy into this idea that I like to call “growth mindset parenting.” Once parents are committed to this idea, it then becomes a concept of how to put it into action. The way we have done this is that we have parceled this into three behaviors that we like to call the 3Ts: Tune In, Talk More, and Take Turns. 

These ideas have come from the audiology/speech-pathology world. “Tuning In” involves using child-directed speech and joint attention. “Talk More” is just as it sounds. It involves using rich vocabulary and talking about the past, the present, and the future, and conceptualizing language. “Take Turns” involves hearing your child as a conversational partner from day one. These 3Ts are at the core of all of our curriculum, and whether or not you are using math and spatial talk, or reading a book, parents can use these 3Ts to ensure that they are providing the richest language environment possible. 

BC: What kind of feedback have you received from families?

DS: What is interesting is that after our first randomized control trial with TMW, we went back and spoke with families to ask about aspects they liked, aspects they didn’t like as well, and opportunities for improvement. We received feedback from parents that they liked the program and were empowered to grow their babies’ brains better. But they also wanted to know how they could assist in improving their child’s behavior and self-regulation. We started to examine how we could use the 3Ts to help a child behave. 

It is important to remember that the early language environment does not just impact vocabulary, math, and spatial abilities, but also socio-emotional development. In the same realm, when you think about what you need to do to help a child learn self-regulation and the behavioral stoplight, parents also need to learn the impact of toxic stress and harsh language in their children’s brain development. We now measure these things. I can’t tell you that using the 3Ts results in less stress environment. But theoretically, if parents use the 3Ts as we imagine, we expect less directive and harsh speech because if you are “Tuned In,” you don’t use that sort of speech. It would be a large overstatement to say that the 3Ts removes toxic stress. There are many things that cause significant stress in the lives of families living in poverty. We view this as one component to assist a family.

BC: How do you find the families participating in your program? 

Image of woman and child.DS: We are actively participating in research so it depends on which program is active. We recruit several ways. With some programs we recruit from daycares, buses, etc. We also have a program that overlays with Universal Newborn Hearing Screening, and we recruit with health-care partners, Pediatrix, and pediatricians. It is much easier to recruit participants through the health-care system.

BC: Is TMW for all children or for children with hearing loss only?

DS: TMW is for all children. I like to call it a public health approach to early learning. We have a touch point with Universal Newborn Hearing Screening. It doesn’t mean that all families need early intervention. We would like to approach a community rollout of who needs what services and where. Not all families living in poverty need the TMW program. And coming from a more affluent family does not mean that TMW strategies aren’t needed. 

BC: What barriers have you encountered implementing successful intervention?

DS: That is a great question. What I can tell you is that working in the health-care system is a much more efficient and effective mechanism for connecting with families. Home visits are a much more natural conduit. But we don’t always have the ability to connect with families at multiple points without the health-care system. We have a challenge with the early childhood piece. When you think of an educational audiologist, the audiologist has the ability to connect with families and children with school. But the early childhood (birth-to-three) is much more challenging for continuity and doesn’t have a similar situation like the school component.

BC: It sounds like success in the program involves multiple touch points with families. Do you have scheduled intervals to meet with families? How do you ensure follow-up?

DS: Each of the interventions has been tested individually. TMW–Home Visiting includes 12 home visits over the course of six months. TMW–Newborn is a single-shot intervention, administered postpartum. TMW–Well Baby is a series of four modules screened at one-, two-, four- and six-month well-child visits. Up to this point, all of our programs have been implemented only in the context of research studies. In this context, follow-ups have been built in to the study timeline at various intervals. As we think about how to embed the entire suite of interventions through existing systems simultaneously, we will embed the follow-up that will be needed to support the work of the various interventions.

Ideally, follow-up for TMW–Newborn and TMW–Well Baby are happening within the health-care system. In the case of the former, audiologists and pediatricians are following up on babies who don’t pass UNHS. In the case of the latter, pediatricians are monitoring and following up on families at risk among their patient population. 

The next step is looking at all of the interventions together in a large rollout. We are looking at a request for partnership with communities around the country moving forward. We want to look at the whole continuum.

BC: What can audiologists do to assist with this?

DS: Audiologists are a key part of this continuum. Our first touch point is through Universal Newborn Hearing Screening. I say that we, as a community, are not just doing the screening because we want to know if a child is deaf. That is important. But language and interaction are the first steps in a developing brain. My hope is that our first collaborations are audiologists and newborn hearing screeners. I would like to build this important first touch point in conveying that parents are so important and critical. And, of course, the important role of the audiologist is expanded and continues if a child is identified with hearing loss.

BC: What is your evidence-based intervention?

DS: The TMW Center’s public-health approach for early learning uses different channels over time to catalyze the role of parents and caregivers. Its multi-touch point behavioral interventions are designed to work across the birth-to-five developmental continuum and reach English- and Spanish-speaking families in settings they naturally frequent.

The first in our set of behavioral interventions, TMW–Newborn is administered in maternity wards during the Universal Hearing Screening. Over the next six months, TMW–Well Baby deepens parent knowledge of foundational brain development at key touch points that overlay the standard immunization schedule at one, two, four, and six months. 

As children move along the developmental continuum, TMW Center for Early Learning + Public Health offers families two options, depending on need: TMW–Home Visiting or TMW–Let’s Talk! The first is home-based; the second offers group classes at community-based organizations. Two forthcoming programs, TMW–Dads and TMW–Healthy Mind, Healthy Body, target select audiences and combine nutrition and education services. In addition, TMW–Early Childhood Educator provides professional development to care providers in center- or home-based child care settings while TMW Center’s preschool curriculum, Cog–X, provides parent academies that teach cognitive and non-cognitive skills to prepare children for success in school. The TMW Center also anticipates a delivery mechanism that will guide families and practitioners to choose the best course of action and appropriate interventions to ensure their needs are met across the birth-to-five continuum. 

BC: You have developed a tool called the SPEAK (Survey of Parents’/Providers’ Expectations and Knowledge) Survey that you plan to use during your presentation at the national convention in Nashville. Can you tell us a little bit about this survey and what makes it so unique? 

DS: I am really excited about this survey because it uses your own data. Basically, it is a clinical and a research survey to see if we understand parent and provider knowledge and belief about parent and child language development. I have shared it with the American Academy of Pediatrics and at a Head Start Conference. It is so fun to see your own data! Of course I suspect the audiologists will get it all right! 

As an audiologist working with a family, it is easy to imagine pondering how much the family you work with knows or doesn’t know. This survey came out of working with families to help them interact more with their children. I needed some sort of tool to measure whether the parent teaching was successful. It started off as a need and evolved into a valuable clinical and research tool. The survey is only 10 questions. Audiologists can use it; pediatricians and early care providers can use it to accurately assess their families. 

BC: What are the take-home messages you would like to share with our readers? 

DS: Thirty Million Words is a translational research program that continually develops and tests a set of evidence-based interventions focused on impacting knowledge, and ultimately changing the behavior of parents and caregivers in an effort to prevent disparities in foundational brain development. Our end goal is a population-level shift in the knowledge, beliefs, and behaviors of parents and adults who interact with and care for young children. We advance a community-wide approach in which our evidence based interventions creates multiple touch points for English and Spanish-speaking families. For example, TMW–Newborn is administered at the Universal Hearing Screening and TMW–Well Baby follows the standard immunization schedule of pediatric well-baby visits. 

The health-care system plays an important role in this community-wide, public health approach, beginning at birth and following children along the continuum of care. Such an approach unifies existing health and education systems, and focuses every effort toward the prevention of early cognitive disparities, and NOT their remediation. 

Our next step is to learn how to bring what we know works to scale. Our new TMW Center for Early Learning + Public Health creates a unique platform for practitioners, researchers, policymakers, and parents to drive healthy brain development and prevent early learning disparities before they start. 

BC: Where can Academy members go to learn more about Thirty Million Words?

DS: Members can visit our TMW Center for Early Learning and Public Health website and the Thirty Million Words Initiative website.

BC: Thank you for taking the time to speak with me today. The Foundation thanks you again for joining us in April. Your evidence-based, early interventions sound very innovative. Thank you for sharing your research with the Academy in Nashville. 

The American Academy of Audiology Foundation, in partnership with The Oticon Foundation, is proud to present the 13th Annual Marion Downs Lecture in Pediatric Audiology at the AAA Annual Conference 2018, April 18–20, in Nashville.