An AAC Personnel Framework: Adults with Acquired Complex Communication Needs

from AAC: Augmentative and Alternative Communication

Interventions that focus on implementing augmentative and alternative communication (AAC) strategies and methods have been available to children in need of AAC and their families for at least 30 years. To date, most of the research that has considered AAC in family settings has been focused on gathering evidence of the effects of AAC interventions, rather than on implementing evidence-based strategies in everyday practice to improve outcomes. The purpose of this article is to discuss the research that has focused on parents as AAC interventionists, the family as a context for AAC intervention, and the effects of AAC interventions on children and other family members. The discussion is framed within the four steps associated with the process of knowledge translation: (a) deciding on desired outcomes of interventions, (b) evaluating evidence of the effectiveness of different AAC methods to obtain the desired outcomes, (c) translating the research evidence into everyday practice, and (d) implementing knowledge in practice.

The Need for Standardization of Methods for Worldwide Infant Hearing Screening: A Systematic Review

from Laryngoscope

Abstract:
No uniform case definition presently exists for infant hearing screening programs worldwide especially for minimal hearing loss (HL). This article systematically reviewed the current practices in developing countries for programs aimed at early detection of “disabling” congenital and early-onset HL and found significant variations which undermine comparability of key findings in the reported studies. Implications for the exclusion of minimal HL are explored within the context of the International Classification of Functioning, Disability and Health (ICF) of the World Health Organization and its adapted version for children and youth (ICF-CY). A revised World Health Organization classification that accounts for all categories of HL based on ICF-CY may provide a suitable framework for improved uniformity in reporting standards.

Evidence-Based Systematic Review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals With Stroke-Induced Aphasia

from the Journal of Speech, Language, and Hearing Research

Purpose: This systematic review summarizes evidence for intensity of treatment and constraint-induced language therapy (CILT) on measures of language impairment and communication activity/participation in individuals with stroke-induced aphasia.

Method: A systematic search of the aphasia literature using 15 electronic databases (e.g., PubMed, CINAHL) identified 10 studies meeting inclusion/exclusion criteria. A review panel evaluated studies for methodological quality. Studies were characterized by research stage (i.e., discovery, efficacy, effectiveness, cost–benefit/public policy research), and effect sizes (ESs) were calculated wherever possible.

Results: In chronic aphasia, studies provided modest evidence for more intensive treatment and the positive effects of CILT. In acute aphasia, 1 study evaluated high-intensity treatment positively; no studies examined CILT. Four studies reported discovery research, with quality scores ranging from 3 to 6 of 8 possible markers. Five treatment efficacy studies had quality scores ranging from 5 to 7 of 9 possible markers. One study of treatment effectiveness received a score of 4 of 8 possible markers.

Conclusion: Although modest evidence exists for more intensive treatment and CILT for individuals with stroke-induced aphasia, the results of this review should be considered preliminary and, when making treatment decisions, should be used in conjunction with clinical expertise and the client’s individual values.

The Need for Standardization of Methods for Worldwide Infant Hearing Screening: A Systematic Review

from Laryngoscope

No uniform case definition presently exists for infant hearing screening programs worldwide especially for minimal hearing loss (HL). This article systematically reviewed the current practices in developing countries for programs aimed at early detection of “disabling” congenital and early-onset HL and found significant variations which undermine comparability of key findings in the reported studies. Implications for the exclusion of minimal HL are explored within the context of the International Classification of Functioning, Disability and Health (ICF) of the World Health Organization and its adapted version for children and youth (ICF-CY). A revised World Health Organization classification that accounts for all categories of HL based on ICF-CY may provide a suitable framework for improved uniformity in reporting standards.

Confusion Over Purpose Of Falls Clinics Compromises Effectiveness Of Service, UK

from Medical News Today.com

An RCP survey of 40 patients in England who had attended a falls clinic following a fall shows that while patients felt the clinics had helped them, they were not always sure about the purpose of the clinic and how it related to their own needs. This misunderstanding leads to patients not continuing with exercises and other activities which could help prevent another fall. In addition, patients were not always given the results of health tests or told about ways of reducing their risk of falling again, and were often unaware of what services were available.

Changes in hearing thresholds over 10 years in older adults

from the Journal of the American Academy of Audiology

Changes in hearing thresholds over a 10-year period in a large population of older adults (2130) ranging in age from 48 to 92 years were documented. Pure-tone thresholds at frequencies from 0.5 to 8 kHz were evaluated at a baseline examination and 2.5, 5, and 10 years later. For younger age groups (50-69 years of age), threshold changes were generally greatest for higher frequencies; in older age groups (70-89 years of age), threshold changes were generally greatest for lower frequencies due to a ceiling effect at higher frequencies. At frequencies of 0.5, 1, 2, and 8 kHz, the pattern of 10-year changes in thresholds across audiometric frequencies was generally similar for men and women. Threshold changes at 4 and 6 kHz were relatively constant for all ages in men across the 10-year examination period; threshold changes at the same frequencies in women increased for the 48-59 and 60-69 years age groups and then tended to level off. Other than age and gender, the best baseline examination predictors of 10-year thresholds at a specific audiometric frequency were the baseline threshold at that frequency followed by the baseline threshold for the next higher test frequency.

Whether SentenceShaper®, a computerized communication system, supports verbal production in individuals with aphasia remains to be seen

from Evidence-Based Communication Assessment and Intervention

No abstract available.

Teaching Graduate Students to Make Evidence-Based Intervention Decisions: Application of a Seven-Step Process Within an Authentic Learning Context

from Topics in Language Disorders

Clinical education provides an authentic context for teaching graduate students how to make evidence-based clinical decisions. We present a seven-step evidence-based practice decision-making process that supervisors can teach graduate students who are enrolled in clinical practicum experiences. Clinical supervisors can teach students to ask appropriate clinical questions, to conduct literature reviews, to critically appraise research evidence, and to systematically integrate external and internal evidence in ways that lead to effective assessment and treatment decisions. The article explains how supervisors can teach the steps in the evidence-based practice decision-making process to students as they answer clinical questions about clients they are serving.

Integration of Evidence-Based Practice Into the University Clinic

from Topics in Language Disorders

For university students, there is often a separation between the research they read and the research discussed in academic courses and the application of that information into the clinical setting. Clinical supervisors help students bridge that gap by making a connection between research and practice, using principles of evidence-based practice. That evidence will come in a number of forms, such as the research literature, systematic reviews, and practice guidelines. In addition, students should avail themselves of the other 2 components of evidence-based practice—clinical judgment (theirs and their supervisor’s) and the goals related to clients and/or families. Students should use their information literacy skills to apply the systematic PICO Procedure (patient characteristics, intervention program, comparison treatment, and outcome) to answer their clinical question and inform their clinical goals. Supervisors should assist students to develop information literacy skills and incorporate these skills within a model of supervision (Anderson, 1988). The purpose of this article is to show how principles of evidence-based practice can be integrated into the university clinic.

Expertise in research-informed clinical decision making: Working effectively with families of children with little or no functional speech

from Evidence-Based Communication Assessment and Intervention

In this article, we consider what is known about how to work effectively with families of children with disabilities, including those with little or no functional speech. Existing evidence about what families want from services is considered, along with information about how expert therapists practice. Our review indicates the importance of understanding family needs, preferences, and priorities, and of being sensitive to the demands of interventions on family life. The augmentative and alternative communication (AAC) literature is linked to the broader literature, confirming what is known about how to work effectively with families and illuminating the contribution of AAC research to this area of knowledge. In general, the AAC literature highlights the importance of the parent-practitioner relationship, of parental involvement and engagement in the intervention process, and of considering the demands that interventions place on families. We conclude that AAC intervention will benefit from continuing therapist efforts to strengthen the client-practitioner relationship through greater situational understanding and appreciation of family perspectives and life circumstances. Therapists’ efforts should also focus on customizing intervention strategies in order to optimize clients’ sense of control, meaningfulness, and engagement.

Evidenced-Based Treatment and Stuttering – Historical Perspective

from the Journal of Speech, Language, and Hearing Research

Purpose: To illustrate the way in which both Fluency Shaping (FS) and Stuttering Management (SM) treatments for developmental stuttering in adults are evidenced-based.

Method: A brief review of the history and development of FS and SM is provided. It illustrates that both can be justified as evidence-based treatments, each having sought evidence of a different kind – FS, evidence concerning treatment outcome; SM, evidence concerning the nature of the stutter event.

Conclusion: While outcome evidence provides the principal support for FS, support for SM comes principally from a cognitive learning model of defensive behavior as applied to the nature of the stutter event. Neither approach can claim anything like uniform success with adults who stutter. However, self-management and modeling are strategies common to both approaches, and have shown consistently positive effects on outcome. It is argued that both strategies merit additional treatment efficacy study. Cognitive behavior theory may provide a useful framework for this research.

Facilitated communication is contraindicated as a treatment choice; a meta-analysis is still to be done

from Evidence-Based Communication Assessment and Intervention

No abstract available.

Determining optimal sample sizes for multi-stage randomized clinical trials using value of information methods

from Clinical Trials

Background Traditional sample size calculations for randomized clinical trials depend on somewhat arbitrarily chosen factors, such as Type I and II errors. An effectiveness trial (otherwise known as a pragmatic trial or management trial) is essentially an effort to inform decision-making, i.e., should treatment be adopted over standard? Taking a societal perspective and using Bayesian decision theory, Willan and Pinto (Stat. Med. 2005; 24:1791-1806 and Stat. Med. 2006; 25:720) show how to determine the sample size that maximizes the expected net gain, i.e., the difference between the cost of doing the trial and the value of the information gained from the results.

Methods These methods are extended to include multi-stage adaptive designs, with a solution given for a two-stage design. The methods are applied to two examples.

Results As demonstrated by the two examples, substantial increases in the expected net gain (ENG) can be realized by using multi-stage adaptive designs based on expected value of information methods. In addition, the expected sample size and total cost may be reduced.

Limitations Exact solutions have been provided for the two-stage design. Solutions for higher-order designs may prove to be prohibitively complex and approximate solutions may be required.

Conclusions The use of multi-stage adaptive designs for randomized clinical trials based on expected value of sample information methods leads to substantial gains in the ENG and reductions in the expected sample size and total cost.

Using enhanced milieu teaching and a voice-output communication aid to increase independent requesting by three children with autism

from Evidence-Based Communication Assessment and Intervention

No abstract available.

Effects of Augmentative and Alternative Communication Intervention on Speech Production in Children With Autism: A Systematic Review

from the American Journal of Speech-Language Pathology

Purpose: This systematic review aimed to determine the effects of augmentative and alternative communication (AAC) intervention on speech production in children with autism or pervasive developmental disorder-not otherwise specified.

Method: A systematic review methodology was utilized to limit bias in searching, selecting, coding, and synthesizing relevant treatment studies. This involved a multifaceted search for studies written between 1975 and May 2007 using various bibliographic databases, dissertation databases, hand searches of selected journals and published compilations of AAC theses and dissertations, and ancestry searches. To be included, studies had to meet stringent criteria. A coding manual and form facilitated data extraction in terms of participant characteristics, treatment characteristics, design and measurement, and outcomes.

Results: Nine single-subject experimental design (27 participants) and 2 group studies (98 participants) were included. Results indicated that AAC interventions do not impede speech production. In fact, most studies reported an increase in speech production. However, in-depth analyses revealed that the gains were rather modest.

Conclusions: Although AAC interventions do not appear to impede speech production and may result in increased speech production, the modest gains observed require realistic expectations among clinicians and other stakeholders. Future research should be more hypothesis driven and aim to identify predictive child characteristics, such as prior speech imitation and object exploration skills.

A randomized, controlled study of computer-based intervention in middle school struggling readers

from Brain and Language

The current study was conducted to test the premise that computer-based intervention that targets auditory temporal processing combined with language exercises (Fast ForWord®) is effective in remediating children with disorders of language and reading. Sixty-five middle school struggling readers were randomly assigned to one of five groups and over a 12-week-period received one of the following interventions: (1) two phases of intervention with Fast ForWord® (FFW, experimental group), (2) two phases of intervention with SuccessMaker (SM, active control group), (3) FFW followed by SM, (4) SM followed by FFW, or (5) no intervention beyond the regular class curriculum (developmental control group). Changes in reading, phonemic awareness, spelling and language skills were assessed via a repeated measures MANOVA. Results indicated significant within-subjects effects (i.e., change for all participants over time), but no between-subject group differences, failing to show that Fast ForWord® resulted in any gains over and above those seen in the other groups.

Dysarthria interventions that address self-monitoring of respiratory and phonatory physiology seem to facilitate use of speech-recognition software

from Evidence-Based Communication Assessment and Intervention

No abstract available.

Intensive dynamic temporal and tactile cueing appears effective for treating some children with severe childhood apraxia of speech

from Evidence-Based Communication Assessment and Intervention

No abstract available.

Tinnitus Retraining Therapy (TRT) for tinnitus

from The Cochrane Library

This is the protocol for a review and there is no abstract. The objectives are as follows:

To assess the effectiveness of Tinnitus Retraining Therapy (TRT) for the treatment of subjective idiopathic tinnitus.

Multimodal therapy for chronic tinnitus

from the International Tinnitus Journal

From 2001 to 2006, we performed a retrospective study of patients suffering from chronic unilateral or bilateral tinnitus that was previously ineffectively treated by oral drugs [betahistine (Betaserc), extract of Ginkgo biloba (EGb 761), tanakan (Tebokan), and cinnarizine-dimenhydrinate (Arlevert), singly or in combination]. We divided 150 tinnitus patients (80 men, 70 women) into seven treatment groups. Treatments consisted of application of intravenous pentoxifylline, lidocaine, or vinpocetine (Cavinton) and combination of these agents with physiotherapy and soft laser. Mean duration (+/- standard deviation) of tinnitus in these patients was 7.4 +/- 6.0 years; their mean age was 55.6 +/- 12.5 years. The aim of our study was to compare treatment modalities and define their effectiveness for tinnitus relief. The most effective treatment was defined as a combination of Cavinton and physiotherapy. We evaluated pure lidocaine infusion therapy as ineffective. None of the treatment modalities had an objective correlate of improvement, though improvement was reported by a visual analog scale.

Exercise Prescription for Dysphagia: Intensity and Duration Manipulation

from the International Tinnitus Journal

This paper briefly reviews information available on exercise stimulus intensity and its interaction with stimulus duration, as well as reviews the current information on different dysphagia treatment modalities as they relate to treatment intensity and duration. The available literature in this area suggests that exercise modalities are distinct and different with regard to the metabolic pathways accessed as a function of both stimulus intensity and duration. Defining treatment prescriptions for dysphagia is difficult at this time, however, because only limited data on stimulus duration or intensity is available for existing indirect and direct treatments. Acknowledgment of exercise physiology paradigms and mechanisms of muscle response to treatment is critical to design of rehabilitation protocols.

Overview of Results From the Largest Clinical Trial for Dysphagia Treatment Efficacy

from Perspectives on Swallowing and Swallowing Disorders (Dysphagia)

Information presented herein provides an overview of the largest randomized clinical trial ever completed in dysphagia. The two-part sequential randomized clinical trial studied the effect of two common dysphagia interventions (chin tuck and thickened liquids) for immediate prevention of aspiration during videofluorographic assessment and also for the incidence of pneumonia at 3-months for patients with Parkinson’s disease and/or dementia. Results indicated that thickened liquids (nectar-thick or honey-thick) prevented aspiration during the radiographic study more frequently than chin-down posture; however, both interventions were equally successful at preventing pneumonia. Adverse events such as urinary tract infection and dehydration were more common with thickened liquids. Median length of hospital stay due to pneumonia was three times longer for patients drinking honey-thick liquids compared to nectar-thick and chin-tuck arms of the study. Several important secondary outcomes are discussed as well as implications for clinical practice. The reader is encouraged to refer to other published works for detailed information that is highlighted in this overview.

Research Consumerism 101: Evaluating External Evidence of Treatment Effectiveness

from Perspectives on Swallowing and Swallowing Disorders (Dysphagia)

The modern clinician is a research consumer. Rehabilitation of oropharyngeal impairments, and prevention of the adverse outcomes of dysphagia, requires the clinician to select interventions for which evidence of a reasonable likelihood of a successful, important outcome exists. The purpose of this paper is to provide strategies for evaluation of published research regarding treatment of oropharyngeal dysphagia. This article utilizes tutorial and examples to inform and educate practitioners in methods of appraising published research. It provides and encourages the use of methods of efficiently evaluating the validity and clinical importance of published research. Additionally, it discusses the importance of the ethical obligation we, as practitioners, have to use evidence-based treatment selection methods and measurement of patient performance during therapy. The reader is provided with tactics for evaluating treatment studies to establish a study’s validity and, thereby, objectively select interventions. The importance of avoiding subjective or unsubstantiated claims and using objective methods of generating empirical clinical evidence is emphasized. The ability to evaluate the quality of research provides clinicians with objective intervention selection as an important, essential component of evidence-based clinical practice.

Whether SentenceShaper®, a computerized communication system, supports verbal production in individuals with aphasia remains to be seen

from Evidence-Based Communication Assessment and Intervention

No abstract available.

A Nationwide Survey of Nonspeech Oral Motor Exercise Use: Implications for Evidence-Based Practice

from Language, Speech, and Hearing Services in Schools

Purpose: A nationwide survey was conducted to determine if speech-language pathologists (SLPs) use nonspeech oral motor exercises (NSOMEs) to address children’s speech sound problems. For those SLPs who used NSOMEs, the survey also identified (a) the types of NSOMEs used by the SLPs, ( b) the SLPs’ underlying beliefs about why they use NSOMEs, (c) SLPs’ training for these exercises, (d) the application of NSOMEs across various clinical populations, and (e) specific tasks/procedures/tools that are used for intervention. Method: A total of 2,000 surveys were mailed to a randomly selected subgroup of SLPs, obtained from the American Speech-Language-Hearing Association (ASHA) membership roster, who self-identified that they worked in various settings with children who have speech sound problems. The questions required answers that used both a forced choice and Likert-type scales. Results: The response rate was 27.5% (537 out of 2,000). Of these respondents, 85% reported using NSOMEs to deal with children’s speech sound production problems. Those SLPs reported that the research literature supports the use of NSOMEs, and that they learned to use these techniques from continuing education events. They also stated that NSOMEs can help improve the speech of children from disparate etiologies, and “warming up” and strengthening the articulators are important components of speech sound therapy. Conclusion: There are theoretical and research data that challenge both the use of NSOMEs and the efficacy of such exercises in resolving speech sound problems. SLPs need to follow the concepts of evidence-based practice in order to determine if these exercises are actually effective in bringing about changes in speech productions. [ABSTRACT FROM AUTHOR]

An Integrated Evaluation of Nonspeech Oral Motor Treatments

from Language, Speech, and Hearing Services in Schools

Purpose: This article functions as an epilogue to the clinical forum examining the use of nonspeech oral motor treatments (NSOMTs) to remediate speech sound disorders in children. Method: Conclusions to eight clinical questions are formed based on the findings that were reported in the clinical forum. Theoretical and clinical challenges are also identified. Conclusion: NSOMTs have serious theoretical and empirical shortcomings. At present, there is insufficient evidence to support the routine clinical application of these procedures to remediate developmental speech sound disorders. [ABSTRACT FROM AUTHOR]

Procedures for Using Clinical Practice Guidelines

from Language, Speech, and Hearing Services in Schools

Purpose: This article provides information about clinical practice guidelines (CPGs) to facilitate their application to the practice of speech-language pathology. CPGs are sets of recommendations based on evidence, including expert clinical opinion, that have been developed by a panel of reviewers. In this article, CPGs are defined and their components and rationale for use are discussed. A guide for analyzing CPGs critically and recommendations for applying them to clinical practice are also described. Method: Two of the authors and 1 graduate student in speechlanguage pathology independently evaluated a CPG from the early intervention literature using the guide described in the article. An illustrative evaluation of a CPG is presented to facilitate application of the proposed critiquing guide. Results: The guide was revealed to have high interrater reliability. However, analysis of the raters’ responses to the individual items revealed problems with 3 items. The authors present possible resolutions and/or explanations for the problems. Conclusion: By using the proposed guide, speech-language pathologists can increase their application of research to clinical practice, thereby enhancing their skills in informed clinical decision making. [ABSTRACT FROM AUTHOR]

The Application of Evidence-Based Practice to Nonspeech Oral Motor Treatments

from Language, Speech, and Hearing Services in Schools

Purpose: The purpose of this article is to help speechlanguage pathologists (SLPs) apply the principles of evidencebased practice (EBP) to nonspeech oral motor treatments (NSOMTs) in order to make valid, evidence-based decisions about NSOMTs and thus determine if they are viable treatment approaches for the management of communication disorders. Method: A detailed description of EBP is provided, including levels of evidence for rating the quality of evidence.NSOMTs are described and a survey of the literature on NSOMTs is provided along with a determination of the level of evidence of each study reported. A systematic literature search was conducted using the electronic databases of MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature) within an unrestricted time period. In addition, reference lists from identified articles were also reviewed. Ethical and fiscal issues related to EBP and NSOMTs, as well as clinical implications of EBP for the use of NSOMTs, are discussed. Results: A to l of 45 articles/reports were published between 1981 and 2006 in peer-reviewed and non-peer-reviewed journals. Most of the sources (25) relied on weak anecdotal evidence and opinions. Moreover, studies that employed stronger designs reported negative results for NSOMTs (i.e., evidence against the use of NSOMTs for modifying speech). Conclusion: Despite their use for many years and their popularity among some SLPs for the treatment of a wide variety of speech problems in children and adults, NSOMTs are controversial because sufficient evidence does not exist to support their effectiveness in improving speech. Moreover, limited evidence exists for the use of NSOMTs to facilitate nonspeech activities. Therefore, the available evidence does not support the continued use of NSOMTs as a standard treatment and they should be excluded from use as a mainstream treatment until there are further data. SLPs should consider the principles of EBP in making decisions… [ABSTRACT FROM AUTHOR]

Outcomes and Efficacy of Newborn Hearing Screening: Strengths and Weaknesses (Success or Failure?)

from Laryngoscope

Abstract:
Objective: To assess the outcomes of neonatal hearing screening with regard to the final diagnosis in a very large number of newborns and investigate related strengths and weaknesses of the program.

Subjects: In this study, 76,560 newborns were assessed.

Method: All neonates were assessed using transient evoked otoacoustic emissions (TEOAEs).

Results: From the 76,560 neonates screened, 1,564 (2%) failed the test. According to the screening protocol, all parents of failed neonates were asked to bring their children 1 month following discharge to repeat the test. Of the 541 (34.6%) newborns who repeated the test, 303 (56%) were found normal and 238 (44%) again failed TEOAE. The latter children were referred to two special public centers for full audiology evaluation. In addition, 124 neonates were also referred due to other reasons revealed in the screening process (family history, high levels of bilirubin, etc.). Of the 362 children who were referred to the two special audiology centers, 113 (31.2%) were evaluated by these two centers. In addition, 42 children who had failed initial screening and did not show up for a follow-up appointment to repeat TEOAE were also assessed in the same centers. Of the 155 children who had a special audiologic evaluation, 56 (36.1%) were found to have hearing loss (HL) and 99 (63.9%) normal hearing. In detail, 28 had bilateral sensorineural HL greater than 40 dB, 10 had unilateral sensorineural HL greater than 40 dB, and 18 had otitis media with effusion or other conductive HL.

Conclusions: Derived from the present study: 1) repeated testing of “failed” newborns in the maternity hospital and before discharge leads to an acceptable referral rate of 2%; 2) the 1-month follow-up of “failed” newborns further limits the false positive results but leads to high rate of newborns lost to follow-up; 3) a dedicated secretariat system should be implemented to follow-up each “failed” newborn and remind parents about their follow-up appointments; and 4) additional measures such as detailed educational material and parental friendly approach should also be implemented.

Outcomes in a Population of Healthy Term and Near-Term Infants With Serum Bilirubin Levels of 325 µmol/L (19 mg/dL) Who Were Born in Nova Scotia, Canada, Between 1994 and 2000

from Pediatrics

OBJECTIVE. The goal was to study the incidence of kernicterus, developmental delay, autism, cerebral palsy, and hearing loss in infants with peak total serum bilirubin levels of 325 µmol/L (19 mg/dL), compared with infants with less-severe or no hyperbilirubinemia, in a population of healthy term and late preterm infants.

METHODS. Prospectively gathered, standardized, maternal and neonatal data for infants at 35 weeks of gestation who were born between January 1, 1994, and December 31, 2000, were extracted from the Nova Scotia Atlee Perinatal Database. Infants with Rh factor isoimmunization, significant congenital or chromosomal abnormalities, or severe peripartum asphyxia were excluded. Comparisons were made on the basis of peak total serum bilirubin levels. Diagnoses were obtained through data linkage with the Medical Services Insurance Database for office visits and the Canadian Institute for Health Information Database for hospital admissions. The registration file provided information allowing calculation of follow-up times, which were determined for each separate outcome. Follow-up periods ranged from 2 to 9 years, with the end point being the first time the diagnostic code was encountered in either database. Cox proportional-hazards regression analyses were used to examine the relationships between outcomes and total serum bilirubin levels.

RESULTS. Of 61238 infants included in the study cohort, 4010 (6.7%) did not have linkage data, which left 56019 infants for analysis. There were no cases of kernicterus and no significant differences in rates of cerebral palsy, deafness, developmental delay, or visual abnormalities between the groups. There were suggestions of associations with attention-deficit disorder in the severe hyperbilirubinemia group and with autism in the combined moderate and severe hyperbilirubinemia group.

CONCLUSIONS. There was no increase in adverse effects reported previously to be associated with bilirubin toxicity. Associations with developmental delay, attention-deficit disorder, and autism were observed.

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Key Words: hyperbilirubinemia • outcomes • population-based