Persistent Language Delay Versus Late Language Emergence in Children With Early Cochlear Implantation

Restricted Speech Recognition in Noise and Quality of Life of Hearing-Impaired Children and Adolescents With Cochlear Implants - Need for Studies Addressing This Topic With Valid Pediatric Quality of Life Instruments

Cochlear implants (CI) support the development of oral language in hearing-impaired children. However, even with CI, speech recognition in noise (SRiN) is limited. This raised the question, whether these restrictions are related to the quality of life (QoL) of children and adolescents with CI and how SRiN and QoL are related to each other. As a result of a systematic literature research only three studies were found, indicating positive moderating effects between SRiN and QoL of young CI users. Thirty studies addressed the quality of life of children and adolescents with CI. Following the criteria of the World Health Organization (WHO) for pediatric health related quality of life HRQoL (1994) only a minority used validated child centered and age appropriate QoL instruments. Moreover, despite the consensus that usually children and adolescents are the most prominent informants of their own QoL (parent-reports complement the information of the children) only a minority of investigators used self-reports. Restricted SRiN may be a burden for the QoL of children and adolescents with CI. Up to now the CI community does not seem to have focused on a possible impairment of QoL in young CI users. Further studies addressing this topic are urgently needed, which is also relevant for parents, clinicians, therapists, teachers, and policy makers. Additionally investigators should use valid pediatric QoL instruments. Most of the young CI users are able to inform about their quality of life themselves.

Morphological Accuracy in the Speech of Bimodal Bilingual Children with CIs

Sign language use in the (re)habilitation of children with cochlear implants (CIs) remains a controversial issue. Concerns that signing impedes spoken language development are based on research comparing children exposed to spoken and signed language (bilinguals) to children exposed only to speech (monolinguals), although abundant research demonstrates that bilinguals and monolinguals differ in language development. We control for bilingualism effects by comparing bimodal bilingual (signing-speaking) children with CIs (BB-CI) to those with typical hearing (BB-TH). Each child had at least one Deaf parent and was exposed to ASL from birth. The BB-THs were exposed to English from birth by hearing family members, while the BB-CIs began English exposure after cochlear implantation around 22-months-of-age. Elicited speech samples were analyzed for accuracy of English grammatical morpheme production. Although there was a trend toward lower overall accuracy in the BB-CIs, this seemed driven by increased omission of the plural -s, suggesting an exaggerated role of perceptual salience in this group. Errors of commission were rare in both groups. Because both groups were bimodal bilinguals, trends toward group differences were likely caused by delayed exposure to spoken language or hearing through a CI, rather than sign language exposure.

Effects of Early Acoustic Hearing on Speech Perception and Language for Pediatric Cochlear Implant Recipients

Purpose The overall goal of the current study was to identify an optimal level and duration of acoustic experience that facilitates language development for pediatric cochlear implant (CI) recipients-specifically, to determine whether there is an optimal duration of hearing aid (HA) use and unaided threshold levels that should be considered before proceeding to bilateral CIs. Method A total of 117 pediatric CI recipients (ages 5-9 years) were given speech perception and standardized tests of receptive vocabulary and language. The speech perception battery included tests of segmental perception (e.g., word recognition in quiet and noise, and vowels and consonants in quiet) and of suprasegmental perception (e.g., talker and stress discrimination, and emotion identification). Hierarchical regression analyses were used to determine the effects of speech perception on language scores, and the effects of residual hearing level (unaided pure-tone average [PTA]) and duration of HA use on speech perception. Results A continuum of residual hearing levels and the length of HA use were represented by calculating the unaided PTA of the ear with the longest duration of HA use for each child. All children wore 2 devices: Some wore bimodal devices, while others received their 2nd CI either simultaneously or sequentially, representing a wide range of HA use (0.03-9.05 years). Regression analyses indicate that suprasegmental perception contributes unique variance to receptive language scores and that both segmental and suprasegmental skills each contribute independently to receptive vocabulary scores. Also, analyses revealed an optimal duration of HA use for each of 3 ranges of hearing loss severity (with mean PTAs of 73, 92, and 111 dB HL) that maximizes suprasegmental perception. Conclusions For children with the most profound losses, early bilateral CIs provide the greatest opportunity for developing good spoken language skills. For those with moderate-to-severe losses, however, a prescribed period of bimodal use may be more advantageous for developing good spoken language skills.

Expressive Vocabulary Predicts Nonverbal Executive Function: A 2-year Longitudinal Study of Deaf and Hearing Children

Numerous studies suggest an association between language and executive function (EF), but evidence of a developmental relationship remains inconclusive. Data were collected from 75 deaf/hard-of-hearing (DHH) children and 82 hearing age-matched controls. Children were 6-11 years old at first time of testing and completed a battery of nonverbal EF tasks and a test of expressive vocabulary. These tasks were completed again 2 years later. Both groups improved their scores on all tasks over this period. DHH children performed significantly less well than hearing peers on some EF tasks and the vocabulary test at both time points. Cross-lagged panel models showed that vocabulary at Time 1 predicted change in EF scores for both DHH and hearing children but not the reverse.

Prosody perception and production by children with cochlear implants

The perception and production of emotional and linguistic (focus) prosody were compared in children with cochlear implants (CI) and normally hearing (NH) peers. Thirteen CI and thirteen hearing-age-matched school-aged NH children were tested, as baseline, on non-verbal emotion understanding, non-word repetition, and stimulus identification and naming. Main tests were verbal emotion discrimination, verbal focus position discrimination, acted emotion production, and focus production. Productions were evaluated by NH adult Dutch listeners. All scores between groups were comparable, except a lower score for the CI group for non-word repetition. Emotional prosody perception and production scores correlated weakly for CI children but were uncorrelated for NH children. In general, hearing age weakly predicted emotion production but not perception. Non-verbal emotional (but not linguistic) understanding predicted CI children's (but not controls') emotion perception and production. In conclusion, increasing time in sound might facilitate vocal emotional expression, possibly requiring independently maturing emotion perception skills.

Functional near-infrared spectroscopy as a tool for assessing speech and spoken language processing in pediatric and adult cochlear implant users

Much of what is known about the course of auditory learning in following cochlear implantation is based on behavioral indicators that users are able to perceive sound. Both prelingually deafened children and postlingually deafened adults who receive cochlear implants display highly variable speech and language processing outcomes, although the basis for this is poorly understood. To date, measuring neural activity within the auditory cortex of implant recipients of all ages has been challenging, primarily because the use of traditional neuroimaging techniques is limited by the implant itself. Functional near-infrared spectroscopy (fNIRS) is an imaging technology that works with implant users of all ages because it is non-invasive, compatible with implant devices, and not subject to electrical artifacts. Thus, fNIRS can provide insight into processing factors that contribute to variations in spoken language outcomes in implant users, both children and adults. There are important considerations to be made when using fNIRS, particularly with children, to maximize the signal-to-noise ratio and to best identify and interpret cortical responses. This review considers these issues, recent data, and future directions for using fNIRS as a tool to understand spoken language processing in children and adults who hear through a cochlear implant.

Development of Phonological, Lexical, and Syntactic Abilities in Children With Cochlear Implants Across the Elementary Grades

PURPOSE

This study assessed phonological, lexical, and morphosyntactic abilities at 6th grade for a group of children previously tested at 2nd grade to address 4 questions: (a) Do children with cochlear implants (CIs) demonstrate deficits at 6th grade? (b) Are those deficits greater, the same, or lesser in magnitude than those observed at 2nd grade? (c) How do the measured skills relate to each other? and (d) How do treatment variables affect outcome measures?

PARTICIPANTS

Sixty-two 6th graders (29 with normal hearing, 33 with CIs) participated, all of whom had their language assessed at 2nd grade.

METHOD

Data are reported for 12 measures obtained at 6th grade, assessing phonological, lexical, and morphosyntactic abilities. Between-groups analyses were conducted on 6th-grade measures and the magnitude of observed effects compared with those observed at 2nd grade. Correlational analyses were performed among the measures at 6th grade. Cross-lagged analyses were performed on specific 2nd- and 6th-grade measures of phonological awareness, vocabulary, and literacy to assess factors promoting phonological and lexical development. Treatment effects of age of 1st CI, preimplant thresholds, and bimodal experience were evaluated.

RESULTS

Deficits remained fairly consistent in type and magnitude across elementary school. The largest deficits were found for phonological skills and the least for morphosyntactic skills, with lexical skills intermediate. Phonological and morphosyntactic skills were largely independent of each other; lexical skills were moderately related to phonological skills but not morphosyntactic skills. Literacy acquisition strongly promoted both phonological and lexical development. Of the treatment variables, only bimodal experience affected outcomes and did so positively.

CONCLUSIONS

Congenital hearing loss puts children at continued risk of language deficits, especially for phonologically based skills. Two interventions that appear to ameliorate that risk are providing a period of bimodal stimulation and strong literacy instruction.

Pairing New Words With Unfamiliar Objects: Comparing Children With and Without Cochlear Implants

PURPOSE

This study investigates differences between preschool children with cochlear implants and age-matched children with normal hearing during an initial stage in word learning to evaluate whether they (a) match novel words to unfamiliar objects and (b) solicit information about unfamiliar objects during play.

METHOD

Twelve preschool children with cochlear implants and 12 children with normal hearing matched for age completed 2 experimental tasks. In the 1st task, children were asked to point to a picture that matched either a known word or a novel word. In the 2nd task, children were presented with unfamiliar objects during play and were given the opportunity to ask questions about those objects.

RESULTS

In Task 1, children with cochlear implants paired novel words with unfamiliar pictures in fewer trials than children with normal hearing. In Task 2, children with cochlear implants were less likely to solicit information about new objects than children with normal hearing. Performance on the 1st task, but not the 2nd, significantly correlated with expressive vocabulary standard scores of children with cochlear implants.

CONCLUSION

This study provides preliminary evidence that children with cochlear implants approach mapping novel words to and soliciting information about unfamiliar objects differently than children with normal hearing.

Executive Function in Deaf Children: Auditory Access and Language Access

Purpose

Deaf children are frequently reported to be at risk for difficulties in executive function (EF); however, the literature is divided over whether these difficulties are the result of deafness itself or of delays/deficits in language that often co-occur with deafness. The purpose of this study is to discriminate these hypotheses by assessing EF in populations where the 2 accounts make contrasting predictions.

Method

We use a between-groups design involving 116 children, ages 5-12 years, across 3 groups: (a) participants with normal hearing (n = 45), (b) deaf native signers who had access to American Sign Language from birth (n = 45), and (c) oral cochlear implant users who did not have full access to language prior to cochlear implantation (n = 26). Measures include both parent report and performance-based assessments of EF.

Results

Parent report results suggest that early access to language has a stronger impact on EF than early access to sound. Performance-based results trended in a similar direction, but no between-group differences were significant.

Conclusions

These results indicate that healthy EF skills do not require audition and therefore that difficulties in this domain do not result primarily from a lack of auditory experience. Instead, results are consistent with the hypothesis that language proficiency, whether in sign or speech, is crucial for the development of healthy EF. Further research is needed to test whether sign language proficiency also confers benefits to deaf children from hearing families.

The Effects of Parent Training on Vocabulary Scores of Young Children With Hearing Loss

PURPOSE

The purpose of this study is to evaluate the effects of short-term parent training on maternal use of language stimulation strategies and vocabulary scores in children with hearing loss.

METHOD

Six mother-child dyads participated in the multiple-baseline study. During baseline and maintenance, children engaged in a business-as-usual model of clinician-only therapy. During intervention, mothers and children participated in parent training focused on transparent labeling and linguistic mapping strategies. Parent strategy use was measured via weekly play-based probe assessments. Child vocabulary growth was measured via parent report.

RESULTS

A relation between parent training and use of transparent labeling was established for all mothers, and a relation between parent training and use of linguistic mapping was established for 3 of 6 mothers. Child vocabulary growth rate increased from baseline to intervention in 4 of 6 children.

CONCLUSIONS

Short-term parent training can change parent behavior. However, parents may not maintain these skills without support. Further research is needed to characterize the extent to which short-term training can make long-term changes in parent and child outcomes.

Early Postimplant Speech Perception and Language Skills Predict Long-Term Language and Neurocognitive Outcomes Following Pediatric Cochlear Implantation

Purpose

We sought to determine whether speech perception and language skills measured early after cochlear implantation in children who are deaf, and early postimplant growth in speech perception and language skills, predict long-term speech perception, language, and neurocognitive outcomes.

Method

Thirty-six long-term users of cochlear implants, implanted at an average age of 3.4 years, completed measures of speech perception, language, and executive functioning an average of 14.4 years postimplantation. Speech perception and language skills measured in the 1st and 2nd years postimplantation and open-set word recognition measured in the 3rd and 4th years postimplantation were obtained from a research database in order to assess predictive relations with long-term outcomes.

Results

Speech perception and language skills at 6 and 18 months postimplantation were correlated with long-term outcomes for language, verbal working memory, and parent-reported executive functioning. Open-set word recognition was correlated with early speech perception and language skills and long-term speech perception and language outcomes. Hierarchical regressions showed that early speech perception and language skills at 6 months postimplantation and growth in these skills from 6 to 18 months both accounted for substantial variance in long-term outcomes for language and verbal working memory that was not explained by conventional demographic and hearing factors.

Conclusion

Speech perception and language skills measured very early postimplantation, and early postimplant growth in speech perception and language, may be clinically relevant markers of long-term language and neurocognitive outcomes in users of cochlear implants.

Supplemental materials

https://doi.org/10.23641/asha.5216200.

Early Sign Language Exposure and Cochlear Implantation Benefits

BACKGROUND

Most children with hearing loss who receive cochlear implants (CI) learn spoken language, and parents must choose early on whether to use sign language to accompany speech at home. We address whether parents' use of sign language before and after CI positively influences auditory-only speech recognition, speech intelligibility, spoken language, and reading outcomes.

METHODS

Three groups of children with CIs from a nationwide database who differed in the duration of early sign language exposure provided in their homes were compared in their progress through elementary grades. The groups did not differ in demographic, auditory, or linguistic characteristics before implantation.

RESULTS

Children without early sign language exposure achieved better speech recognition skills over the first 3 years postimplant and exhibited a statistically significant advantage in spoken language and reading near the end of elementary grades over children exposed to sign language. Over 70% of children without sign language exposure achieved age-appropriate spoken language compared with only 39% of those exposed for 3 or more years. Early speech perception predicted speech intelligibility in middle elementary grades. Children without sign language exposure produced speech that was more intelligible (mean = 70%) than those exposed to sign language (mean = 51%).

CONCLUSIONS

This study provides the most compelling support yet available in CI literature for the benefits of spoken language input for promoting verbal development in children implanted by 3 years of age. Contrary to earlier published assertions, there was no advantage to parents' use of sign language either before or after CI.

Consonant Acquisition in Young Cochlear Implant Recipients and Their Typically Developing Peers

PURPOSE

Consonant acquisition was examined in 13 young cochlear implant (CI) recipients and 11 typically developing (TD) children.

METHOD

A longitudinal research design was implemented to determine the rate and nature of consonant acquisition during the first 2 years of robust hearing experience. Twenty-minute adult-child (typically a parent) interactions were video and audio recorded at 3-month intervals following implantation until 24 months of robust hearing experience was achieved. TD children were similarly recorded between 6 and 24 months of age. Consonants that were produced twice within a 50-utterance sample were considered "established" within a child's consonant inventory.

RESULTS

Although the groups showed similar trajectories, the CI group produced larger consonant inventories than the TD group at each interval except for 21 and 24 months. A majority of children with CIs also showed more rapid acquisition of consonants and more diverse consonant inventories than TD children.

CONCLUSIONS

These results suggest that early auditory deprivation does not significantly affect consonant acquisition for most CI recipients. Tracking early consonant development appears to be a useful way to assess the effectiveness of cochlear implantation in young recipients.

Development of Grammatical Accuracy in English-Speaking Children With Cochlear Implants: A Longitudinal Study

PURPOSE

We sought to evaluate the development of grammatical accuracy in English-speaking children with cochlear implants (CIs) over a 3-year span.

METHOD

Ten children who received CIs before age 30 months participated in this study at 3, 4, and 5 years postimplantation. For the purpose of comparison, 10 children each at ages 3, 4, and 5 years with typical hearing were included as well. All children participated in a story-retell task. We computed percent grammatical communication units (PGCU) in the task.

RESULTS

Children with CIs showed significant improvement in PGCU over the 3-year span. However, they produced lower PGCU than children with typical hearing who had matched hearing age at 4 and 5 years postimplantation. At the individual level, some children with CIs were able to produce PGCU comparable to children with typical hearing as early as 3 years after implantation. Better speech-perception skills at earlier time points were associated with higher PGCU at later time points. Moreover, children with and without CIs showed similar rankings in the types of grammatical errors.

CONCLUSION

Despite having auditory-perceptual and information-processing constraints, children who received CIs before age 30 months were able to produce grammatical sentences, albeit with a delayed pattern.

Are we slipping them through the cracks? The insufficiency of norm-referenced assessments for identifying language weaknesses in children with hearing loss

Children with hearing loss who use listening and spoken language increasingly reach performance within or above the average range on norm-referenced assessments of language ability prior to entering school; however, they continue to perform below expectations on language-based academic skills, such as reading. The purpose of this article was to identify limitations of making service provision decisions primarily on the basis of norm-referenced assessments for children with hearing loss. We offer evidence from a group of children with hearing loss who scored within 1.5 standard deviations of the mean on a norm-referenced omnibus language measure. These children with hearing loss performed more poorly than age-matched children with normal hearing on several measures derived from a naturalistic language sample. Based on the limitations of norm-referenced assessments and the findings of this study, we propose that language sample analysis should be used as primary evidence of language weakness for children with hearing loss.

New language outcome measures for Mandarin speaking children with hearing loss

Objective

The paper discusses recent evidence on the assessment of language outcomes in children with hearing loss acquiring oral language.

Methods

Research emphasizes that language tests must be specific enough to capture subtle deficits in vocabulary and grammar learning at different developmental ages. The Diagnostic Receptive and Expressive Assessment of Mandarin (DREAM) was carefully designed to be a comprehensive standardized Mandarin assessment normed in Mainland China.

Results

This paper summarizes the evidence-based item design process and validity and reliability results of DREAM. A pilot study reported here shows that DREAM provided detailed information about hearing impaired children's language abilities and can be used to aid intervention planning to maximize progress.

Conclusion

DREAM represents an example of translational science, transferring methods from empirical studies of language acquisition in research environments into applied domains such as assessment and intervention. Research on outcomes in China will advance significantly with the availability of evidence-based comprehensive language tests that measure a sufficient age range of skills, are normed on Mandarin speaking children in mainland China, and are designed to capture features central to Mandarin language acquisition.

Specific Language Impairment, Nonverbal IQ, Attention-Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, Cochlear Implants, Bilingualism, and Dialectal Variants: Defining the Boundaries, Clarifying Clinical Conditions, and Sorting Out Causes

PURPOSE

The purpose of this research forum article is to provide an overview of a collection of invited articles on the topic "specific language impairment (SLI) in children with concomitant health conditions or nonmainstream language backgrounds." Topics include SLI, attention-deficit/hyperactivity disorder, autism spectrum disorder, cochlear implants, bilingualism, and dialectal language learning contexts.

METHOD

The topic is timely due to current debates about the diagnosis of SLI. An overarching comparative conceptual framework is provided for comparisons of SLI with other clinical conditions. Comparisons of SLI in children with low-normal or normal nonverbal IQ illustrate the unexpected outcomes of 2 × 2 comparison designs.

RESULTS

Comparative studies reveal unexpected relationships among speech, language, cognitive, and social dimensions of children's development as well as precise ways to identify children with SLI who are bilingual or dialect speakers.

CONCLUSIONS

The diagnosis of SLI is essential for elucidating possible causal pathways of language impairments, risks for language impairments, assessments for identification of language impairments, linguistic dimensions of language impairments, and long-term outcomes. Although children's language acquisition is robust under high levels of risk, unexplained individual variations in language acquisition lead to persistent language impairments.