What can we expect of normally-developing children implanted at a young age with respect to their auditory, linguistic and cognitive skills?

Language profile of children with cochlear implants: comparative study about the effect of age of cochlear implantation and the duration of rehabilitation

PURPOSE

The analysis of different language domains and exploration of variables that affect the outcomes of cochlear implantation would help to document the efficacy of cochlear implantation and intervention programs. The aim of this work was to examine the language profile of children with Cochlear Implants (CI) and to assess the effect of age at the time of cochlear implantation and the impact of duration of rehabilitation on the development of linguistic abilities for cochlear implanted children.

METHODS

The study was conducted on 46 Arabic speaking children using unilateral CI who are receiving regular post-cochlear auditory and language rehabilitation in the phoniatrics unit, Kasr Alaini hospital. A Proficient Preschooler Language Evaluation (APPEL TOOL) was applied for the assessment of different language domains.

RESULTS

Children who received post implant rehabilitation for ≥ 2 years showed significant improvement in all subtests' scores of APPEL tool than children who received same rehabilitation for ≤ 1 year. There was no significant difference of language scores between children who have received CI before age of 3 years and those who have been implanted after age of 3 years.

CONCLUSION

This study showed that the language profile of CI children was beneficially affected by the longer duration of therapy post implantation.

Similar gaze behaviour during dialogue perception in congenitally deaf children with cochlear Implants and normal hearing children

BACKGROUND

Perceptual and speech production abilities of children with cochlear implants (CIs) are usually tested by word and sentence repetition or naming tests. However, these tests are quite far apart from daily life linguistic contexts.

AIM

Here, we describe a way of investigating the link between language comprehension and anticipatory verbal behaviour promoting the use of more complex listening situations.

METHODS AND PROCEDURE

The setup consists in watching the audio-visual dialogue of two actors. Children's gaze switches from one speaker to the other serve as a proxy of their prediction abilities. Moreover, to better understand the basis and the impact of anticipatory behaviour, we also measured children's ability to understand the dialogue content, their speech perception and memory skills as well as their rhythmic skills, that also require temporal predictions. Importantly, we compared children with CI performances with those of an age-matched group of children with normal hearing (NH).

OUTCOMES AND RESULTS

While children with CI revealed poorer speech perception and verbal working memory abilities than NH children, there was no difference in gaze anticipatory behaviour. Interestingly, in children with CI only, we found a significant correlation between dialogue comprehension, perceptual skills and gaze anticipatory behaviour.

CONCLUSION

Our results extend to a dialogue context of previous findings showing an absence of predictive deficits in children with CI. The current design seems an interesting avenue to provide an accurate and objective estimate of anticipatory language behaviour in a more ecological linguistic context also with young children.

WHAT THIS PAPER ADDS

What is already known on the subject Children with cochlear implants seem to have difficulties extracting structure from and learning sequential input patterns, possibly due to signal degradation and auditory deprivation in the first years of life. They also seem to have a reduced use of contextual information and slow language processing among children with hearing loss. What this paper adds to existing knowledge Here we show that when adopting a rather complex linguistic context such as watching a dialogue of two individuals, children with cochlear implants are able to use the speech and language structure to anticipate gaze switches to the upcoming speaker. What are the clinical implications of this work? The present design seems an interesting avenue to provide an accurate and objective estimate of anticipatory behaviour in a more ecological and dynamic linguistic context. Importantly, this measure is implicit and it has been previously used with very young (normal-hearing) children, showing that they spontaneously make anticipatory gaze switches by age two. Thus, this approach may be of interest to refine the speech comprehension assessment at a rather early age after cochlear implantation where explicit behavioural tests are not always reliable and sensitive.

Language, cognitive, and speech in noise perception abilities of children with cochlear ımplants: a comparative analysis by implantation period and bilateral versus unilateral cochlear implants

PURPOSE

The purpose of this study was to compare the language, cognitive, and speech in noise (SiN) perception abilities of children with cochlear implants (CIs) to those of their peers with NH by grouping them according to their implantation period (12-18 months/19-24 months) and unilateral/bilateral CI use.

METHODS

The sample comprised 50 children with cochlear implants (CIs) and 20 children with normal hearing (NH), ages 6-9 years. Children's language, cognitive, and speech in noise (SiN) perception skills were assessed.

RESULTS

Children with CIs between 12 and 18 months and 19 and 24 months performed more poorly than children with NH on language, verbal memory (VM), verbal-short-term memory (V-STM), verbal working memory (V-WM), rapid naming, and speech in noise (SiN) perception abilities measures (p < 0.001). In addition, children with CIs between 19 and 24 months performed worse on rapid naming and V-WM tasks than children with CIs between 12 and 18 months (p < 0.017). Children with unilateral and bilateral CI performed more poorly than children with NH on language, VM, V-STM, V-WM, rapid naming, and SiN perception abilities assessments (p < 0.001). Additionally children with unilateral CI users performed poorly than children with bilateral CI users on SiN perception (p < 0.017).

CONCLUSIONS

In children with congenital hearing loss (CHL), cochlear implantation between 12 and 18 months or sequential bilateral implantation is not sufficient for these children to perform like their NH peers in language, cognitive, and SiN perception abilities. In addition, intervention approaches should focus not only on increasing language skills, but also on cognitive abilities.

Interventions for Developmental Language Delay and Disorders

BACKGROUND

Approximately 9.9 % of children present with difficulties in language development (DLD), 7.6 % without serious additional impairments and 2.3 % associated with languagerelevant comorbidities, e.g., hearing loss. Notably, in a consensus statement by experts in German-speaking countries, in the guideline presented here, and further in this article, all of these disorders are referred to as "developmental language disorders" (DLD), whereas the international consortium CATALISE only refers to those without comorbidities as DLD. DLDs are among the most commonly treated childhood disorders and, if persistent, often reduce educational and socio-economic outcome. Children in their third year of life with developmental language delay (late talkers, LT) are at risk of a later DLD.

METHODS

This German interdisciplinary clinical practice guideline reflects current knowledge regarding evidence-based interventions for developmental language delay and disorders. A systematic literature review was conducted on the effectiveness of interventions for DLD.

RESULTS

The guideline recommends parent training (Hedges g = 0.38 to 0.82) for LTs with expressive language delay, language therapy (Cohen's d = -0.20 to 0.90) for LTs with additional receptive language delay or further DLD risk factors, phonological or integrated phonological treatment methods (Cohen's d = 0.89 to 1.04) for phonological speech sound disorders (SSDs), a motor approach for isolated phonetic SSDs (non-DLD), and for lexical-semantic and morpho-syntactic impairments combinations of implicit and explicit intervention approaches (including input enrichment, modeling techniques, elicitation methods, creation of production opportunities, metalinguistic- approaches, visualizations; Cohen's d = 0.89-1.04). Recom mendations were also made for DLD associated with pragmatic-communicative impairment, bi-/ multilingualism, hearing loss, intellectual disability, autism-spectrum disorders, selective mutism, language- relevant syndromes or multiple disabilities, and for intensive inpatient language rehabilitation.

CONCLUSION

Early parent- and child-centered speech and language intervention implementing evidence-based intervention approaches, frequency, and settings, combined with educational language support, can improve the effectiveness of management of developmental language delay and disorders.

Foreign Language Acquisition in Adolescent Cochlear Implant Users

OBJECTIVES

This study explores to what degree adolescent cochlear implant (CI) users can learn a foreign language in a school setting similar to their normal-hearing (NH) peers despite the degraded auditory input.

DESIGN

A group of native Dutch adolescent CI users (age range 13 to 17 years) learning English as a foreign language at secondary school and a group of NH controls (age range 12 to 15 years) were assessed on their Dutch and English language skills using various language tasks that either relied on the processing of auditory information (i.e., listening task) or on the processing of orthographic information (i.e., reading and/or gap-fill task). The test battery also included various auditory and cognitive tasks to assess whether the auditory and cognitive functioning of the learners could explain the potential variation in language skills.

RESULTS

Results showed that adolescent CI users can learn English as a foreign language, as the English language skills of the CI users and their NH peers were comparable when assessed with reading or gap-fill tasks. However, the performance of the adolescent CI users was lower for English listening tasks. This discrepancy between task performance was not observed in their native language Dutch. The auditory tasks confirmed that the adolescent CI users had coarser temporal and spectral resolution than their NH peers, supporting the notion that the difference in foreign language listening skills may be due to a difference in auditory functioning. No differences in the cognitive functioning of the CI users and their NH peers were found that could explain the variation in the foreign language listening tasks.

CONCLUSIONS

In short, acquiring a foreign language with degraded auditory input appears to affect foreign language listening skills, yet does not appear to impact foreign language skills when assessed with tasks that rely on the processing of orthographic information. CI users could take advantage of orthographic information to facilitate foreign language acquisition and potentially support the development of listening-based foreign language skills.

Sustainable Benefits of High Variability Phonetic Training in Mandarin-speaking Kindergarteners With Cochlear Implants: Evidence From Categorical Perception of Lexical Tones

OBJECTIVES

Although pitch reception poses a great challenge for individuals with cochlear implants (CIs), formal auditory training (e.g., high variability phonetic training [HVPT]) has been shown to provide direct benefits in pitch-related perceptual performances such as lexical tone recognition for CI users. As lexical tones in spoken language are expressed with a multitude of distinct spectral, temporal, and intensity cues, it is important to determine the sources of training benefits for CI users. The purpose of the present study was to conduct a rigorous fine-scale evaluation with the categorical perception (CP) paradigm to control the acoustic parameters and test the efficacy and sustainability of HVPT for Mandarin-speaking pediatric CI recipients. The main hypothesis was that HVPT-induced perceptual learning would greatly enhance CI users' ability to extract the primary pitch contours from spoken words for lexical tone identification and discrimination. Furthermore, individual differences in immediate and long-term gains from training would likely be attributable to baseline performance and duration of CI use.

DESIGN

Twenty-eight prelingually deaf Mandarin-speaking kindergarteners with CIs were tested. Half of them received five sessions of HVPT within a period of 3 weeks. The other half served as control who did not receive the formal training. Two classical CP tasks on a tonal continuum from Mandarin tone 1 (high-flat in pitch) to tone 2 (mid-rising in pitch) with fixed acoustic features of duration and intensity were administered before (pretest), immediately after (posttest), and 10 weeks posttraining termination (follow-up test). Participants were instructed to either label a speech stimulus along the continuum (i.e., identification task) or determine whether a pair of stimuli separated by zero or two steps from the continuum was the same or different (i.e., discrimination task). Identification function measures (i.e., boundary position and boundary width) and discrimination function scores (i.e., between-category score, within-category score, and peakedness score) were assessed for each child participant across the three test sessions.

RESULTS

Linear mixed-effects (LME) models showed significant training-induced enhancement in lexical tone categorization with significantly narrower boundary width and better between-category discrimination in the immediate posttest over pretest for the trainees. Furthermore, training-induced gains were reliably retained in the follow-up test 10 weeks after training. By contrast, no significant changes were found in the control group across sessions. Regression analysis confirmed that baseline performance (i.e., boundary width in the pretest session) and duration of CI use were significant predictors for the magnitude of training-induced benefits.

CONCLUSIONS

The stringent CP tests with synthesized stimuli that excluded acoustic cues other than the pitch contour and were never used in training showed strong evidence for the efficacy of HVPT in yielding immediate and sustained improvement in lexical tone categorization for Mandarin-speaking children with CIs. The training results and individual differences have remarkable implications for developing personalized computer-based short-term HVPT protocols that may have sustainable long-term benefits for aural rehabilitation in this clinical population.

Effectiveness of rhythmic training on linguistics skill development in deaf children and adolescents with cochlear implants: A systematic review

OBJECTIVE

This review compiles the scientific evidence to date on the effectiveness of musical/rhythmic training for improving and/or enhancing the development of language skills in deaf children aged 6-16 years with cochlear implants.

METHODS

PubMed, ScienceDirect, and Web of Science were used for the research following the PRISMA protocol.

RESULTS

The reviewed studies indicate that rhythmic training can improve language skills (perception, production, and comprehension) in this population, as well as in other cognitive skills.

CONCLUSION

Although further research is still needed, the current evidence can help identify new and more effective early intervention methods for deaf children.

The Development of Left Hemisphere Lateralization for Sentence-Level Prosodic Processing

PURPOSE

The fine-tuning of linguistic prosody in later childhood is poorly understood, and its neurological processing is even less well studied. In particular, it is unknown if grammatical processing of prosody is left- or right-lateralized in childhood versus adulthood and how phonological working memory might modulate such lateralization. Furthermore, it is virtually unknown how prosody develops neurologically among children with cochlear implants (CIs).

METHOD

Normal-hearing (NH) children ages 6-12 years and NH adults ages 18-28 years completed a functional near-infrared spectroscopy neuroimaging task, during which they heard sentence pairs and judged whether the sentences did or did not differ in their overall prosody (declarative, question, with or without narrow focus). Children also completed standard measures of expressive and receptive language.

RESULTS

Age group differences emerged; children exhibited stronger bilateral temporoparietal activity but reduced left frontal activation. Furthermore, children's performance on a nonword repetition test was significantly associated with activation in the left inferior frontal gyrus-an area that was generally more activated in adults than in children.

CONCLUSIONS

The prosody-related findings are generally consistent with prior neurodevelopmental works on sentence comprehension, especially those involving syntax and semantics, which have also noted a developmental shift from bilateral temporal to left inferior frontal regions typically associated with increased sensitivity to sentence structure. The findings thus inform theoretical perspectives on brain and language development and have implications for studying the effects of CIs on neurodevelopmental processes for sentence prosody.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22255996.

The development of cortical processing of speech differs between children with cochlear implants and normal hearing and changes with parental singing

Objective

The aim of the present study was to investigate speech processing development in children with normal hearing (NH) and cochlear implants (CI) groups using a multifeature event-related potential (ERP) paradigm. Singing is associated to enhanced attention and speech perception. Therefore, its connection to ERPs was investigated in the CI group.

Methods

The paradigm included five change types in a pseudoword: two easy- (duration, gap) and three difficult-to-detect (vowel, pitch, intensity) with CIs. The positive mismatch responses (pMMR), mismatch negativity (MMN), P3a and late differentiating negativity (LDN) responses of preschoolers (below 6 years 9 months) and schoolchildren (above 6 years 9 months) with NH or CIs at two time points (T1, T2) were investigated with Linear Mixed Modeling (LMM). For the CI group, the association of singing at home and ERP development was modeled with LMM.

Results

Overall, responses elicited by the easy- and difficult to detect changes differed between the CI and NH groups. Compared to the NH group, the CI group had smaller MMNs to vowel duration changes and gaps, larger P3a responses to gaps, and larger pMMRs and smaller LDNs to vowel identity changes. Preschoolers had smaller P3a responses and larger LDNs to gaps, and larger pMMRs to vowel identity changes than schoolchildren. In addition, the pMMRs to gaps increased from T1 to T2 in preschoolers. More parental singing in the CI group was associated with increasing pMMR and less parental singing with decreasing P3a amplitudes from T1 to T2.

Conclusion

The multifeature paradigm is suitable for assessing cortical speech processing development in children. In children with CIs, cortical discrimination is often reflected in pMMR and P3a responses, and in MMN and LDN responses in children with NH. Moreover, the cortical speech discrimination of children with CIs develops late, and over time and age, their speech sound change processing changes as does the processing of children with NH. Importantly, multisensory activities such as parental singing can lead to improvement in the discrimination and attention shifting toward speech changes in children with CIs. These novel results should be taken into account in future research and rehabilitation.

Phonological Awareness and Working Memory in Mandarin-Speaking Preschool-Aged Children With Cochlear Implants

PURPOSE

Cochlear implants (CIs) provide significant benefits for profoundly deaf children in their language and cognitive development. However, it remains unclear whether Mandarin-speaking young children with early implantation can develop age-equivalent phonological awareness (PA) skill and working memory (WM) capacity as their normal hearing (NH) peers. The aim of this study was to investigate PA and WM in preschool-aged children with or without hearing loss and to examine the relationship between the two basic skills.

METHOD

The data were collected from 16 Mandarin-speaking preschoolers with CIs and 16 age-matched children with NH. All preschool participants were instructed to complete four phonological detection tasks and four digit span tasks. Linear mixed-effects modeling was performed to evaluate PA and WM performances between two groups across different tasks.

RESULTS

CI preschoolers showed comparable performances on par with NH controls in phonological detections and visual digit spans. In addition, Pearson correlation analysis revealed a positive relationship between phonological detections and auditory digit spans in preschool-aged children with CIs.

CONCLUSION

With early implantation, the congenitally deaf children were capable of developing age-appropriate PA skill and WM capacity, which have practical implications for aural rehabilitation in this special pediatric population.

Lilliput: speech perception in speech-weighted noise and in quiet in young children

OBJECTIVE

The aim of this study was to develop an open-set word recognition task in speech-weighted noise and in quiet for young children and examine age effects for open versus closed response formats.

DESIGN

Dutch monosyllabic words were presented in quiet and in stationary speech-weighted noise to 4- and 5-year-old children as well as to young adults in an open-set response format. Additionally, performance in open and closed context was assessed, as well as in a picture-pointing paradigm.

STUDY SAMPLE

More than 200 children and 50 adults with normal hearing participated in the various validation phases.

RESULTS

Average fitted speech reception thresholds (50%) yielded an age effect between 4-year and 5-year olds (and adults), both in speech-weighted noise and in quiet. The closed-set format yielded lower (better) SNRs than the open-set format, and children benefitted to the same extent as adults from phonetically similar words in speech-weighted noise. Additionally, the 4 AFC picture-pointing paradigm can be used to assess word recognition in quiet from 3 years of age.

CONCLUSIONS

The same materials reveal performance differences between 4 and 5 years of age (and adults), both in quiet and speech-weighted noise using an open-set response format. This relatively small yet significant difference in SRT for a gap of only 1 year shows a developmental change for word recognition in speech-weighted noise and in quiet in the first decade of life.The study is part of the protocol registered on ClinicalTrials.gov (ID = NCT04063748).

Home language maintenance in bilingual children with normal hearing and with hearing loss who use cochlear implants

We investigated home language (Spanish) maintenance in Spanish- and English-speaking bilingual children with normal hearing (NH) and their peers with hearing loss (HL) who used cochlear implants (CIs) at two time points about 7 months apart. Twenty-two bilingual children (11 with NH and 11 with CIs) between the ages of 4;6 and 7;11 participated in the study, who were matched as closely as possible on chronological age, time elapsed between the first and the second sample, gender, and age of exposure to their languages across groups. We compared group performance on the Preschool Language Scales - 5^th edition (PLS-5) and the Word Intelligibility Picture Identification at each time point as well as home language maintenance calculated based on item responses on the PLS-5. Our results indicated differences on all measures at both time points between the performance of children with NH and their peers with HL who used CIs in that the former group outperformed the latter. We also found that bilingual children with NH maintained their home language at a higher level than their peers with HL who used CIs. Further, the data also showed that despite the group differences, both groups displayed maintenance of their home language and that individual variability was more prevalent in the CI group. We conclude that home language maintenance is not only possible, but it should be encouraged for both bilingual children with NH and their peers with HL who used CIs.

Receptive Vocabulary of Children With Bilateral Cochlear Implants From 3 to 16 Years of Age

OBJECTIVES

The vocabulary of children with cochlear implants is often smaller than that of their peers with typical hearing, but there is uncertainty regarding the extent of the differences and potential risks and protective factors. Some studies indicate that their receptive vocabulary develops well at first, but that they fail to keep up with their typical hearing peers, causing many CI users to enter school with a receptive vocabulary that is not age-appropriate. To better understand the receptive vocabulary abilities of children with cochlear implants this study explored age-related differences to matched children with typical hearing and associations between vocabulary skills and child-level characteristics.

DESIGN

A retrospective cross-sectional study with matched controls was conducted at the Norwegian national cochlear implant center at Oslo University Hospital. Eighty-eight children (mean age 8.7 years; range 3.2 to 15.9; 43 girls, 45 boys) who had received bilateral cochlear implants before 3 years of age were compared with two groups of children with typical hearing. One group was matched for maternal education, sex, and chronological age, the other group was matched for maternal education, sex, and hearing age. Receptive vocabulary performance was measured with the British Picture Vocabulary Scale.

RESULTS

Cochlear implant users' receptive vocabulary was poorer than that of age-matched children with typical hearing ( M = 84.6 standard points, SD = 21.1; children with typical hearing: M = 102.1 standard points, SD = 15.8; mean difference -17.5 standard points, 95% CI [-23.0 to -12.0], p < 0.001; Hedges's g = -0.94, 95% CI [-1.24 to -0.62]), and children with cochlear implants were significantly more likely to perform below the normative range (risk ratio = 2.2, 95% CI [1.42 to 3.83]). However, there was a significant nonlinear U-shaped effect of age on the scores of cochlear implant users, with the difference to the matched typical hearing children being largest (23.9 standard points, on average) around 8.7 years of age and smaller toward the beginning and end of the age range. There was no significant difference compared with children with typical hearing when differences in auditory experience were accounted for. Variability was not significantly different between the groups. Further analysis with a random forest revealed that, in addition to chronological age and hearing age, simultaneous versus sequential implantation, communication mode at school, and social integration were predictors of cochlear implant users' receptive vocabulary.

CONCLUSIONS

On average, the receptive vocabulary of children with cochlear implants was smaller than that of their typical hearing peers. The magnitude of the difference was changing with age and was the largest for children in early primary school. The nonlinear effect of age might explain some of the ambiguity in previous research findings and could indicate that better intervention is required around school entry. The results emphasize that continuous monitoring and support are crucial to avoid far-reaching negative effects on the children's development and well-being.

Morpho-Syntactic Deficit in Children with Cochlear Implant: Consequence of Hearing Loss or Concomitant Impairment to the Language System?

BACKGROUND

Among implanted children with similar duration of auditory deprivation and clinical history, the morpho-syntactic skills remain highly variable, suggesting that other fundamental factors may determine the linguistic outcomes of these children, beyond their auditory recovery. The present study analyzed the morpho-syntactic discrepancies among three children with cochlear implant (CI), with the aim of understanding if morpho-syntactic deficits may be characterized as a domain-specific language disorder.

METHOD

The three children (mean age = 7.2; SD = 0.4) received their CI at 2.7, 3.7, and 5.9 years of age. Their morpho-syntactic skills were evaluated in both comprehension and production and compared with 15 age-matched normal-hearing children (mean age = 6.6; SD = 0.3).

RESULTS

Cases 1 and 2 displayed a marked impairment across morphology and syntax, whereas Case 3, the late-implanted child, showed a morpho-syntactic profile well within the normal boundaries. A qualitative analysis showed, in Cases 1 and 2, language deficits similar to those of normal hearing children with Developmental Language Disorder (DLD).

CONCLUSIONS

We suggest that a severe grammatical deficit may be, in some implanted children, the final outcome of a concomitant impairment to the language system. Clinical implications for assessment and intervention are discussed.

Sonority-Related Novel Word Learning Ability of Children With Cochlear Implants With Optimal Oral Language Exposure

OBJECTIVES

The present study investigated how children with cochlear implants (CIs), with optimal exposure to oral language, perform on sonority-related novel word learning tasks. By optimal oral language exposure, we refer to bilateral cochlear implantation below the age of 2 years. Sonority is the relative perceptual prominence/loudness of speech sounds of the same length, stress, and pitch. The present study is guided by a previous study that investigated the sonority-related novel word learning ability of a group of children with CIs, in the Greek language, of which the majority were implanted beyond the age of 2 unilaterally.

DESIGN

A case-control study with 15 Dutch-speaking participants in each of the three groups, i.e., children with CIs, normal-hearing children (NHC), and normal-hearing adults, was conducted using a sonority-related novel "CVC" word learning task. All children with CIs are implanted before the age of 2 years with preimplant hearing aids. Thirteen out of the 15 children had bilateral CIs. The CVC words were constructed according to four sonority conditions, where N is nonsonorous and S is a sonorous phoneme: NSN, NSS, SSN, and SSS. Outcome measures were accuracy and reaction times (RTs). In addition, the Peabody picture vocabulary test and the digit span forward test were administered to the children.

RESULTS

There were no statistical differences in accuracy or RTs between the children groups on the overall score and across the different conditions. However, children with CIs, unlike NHC, scored statistically less accurately and with longer RTs relative to normal-hearing adults, on the overall task. Within-group comparisons showed that none of the groups performed statistically differently on any of the conditions. The NHC showed higher receptive vocabulary scores relative to children with CIs. In addition, the group of children with CIs entailed a statistically significantly higher number of children with "weak" short-term memory.

CONCLUSIONS

Children with CIs who have optimal oral language exposure showed age-appropriate sonority-related novel word learning abilities and strategies relative to their NH peers. However, children with CIs continue to show lower receptive vocabulary scores than NHC, despite the equivalent novel word learning ability. This suggests that children with CIs may have difficulties in retaining newly learned words. Future work should look into possible causes of the gap in performance. This would eventually aid in rehabilitation tailored to the needs of the individual.

Links of Prosodic Stress Perception and Musical Activities to Language Skills of Children With Cochlear Implants and Normal Hearing

OBJECTIVES

A major issue in the rehabilitation of children with cochlear implants (CIs) is unexplained variance in their language skills, where many of them lag behind children with normal hearing (NH). Here, we assess links between generative language skills and the perception of prosodic stress, and with musical and parental activities in children with CIs and NH. Understanding these links is expected to guide future research and toward supporting language development in children with a CI.

DESIGN

Twenty-one unilaterally and early-implanted children and 31 children with NH, aged 5 to 13, were classified as musically active or nonactive by a questionnaire recording regularity of musical activities, in particular singing, and reading and other activities shared with parents. Perception of word and sentence stress, performance in word finding, verbal intelligence (Wechsler Intelligence Scale for Children (WISC) vocabulary), and phonological awareness (production of rhymes) were measured in all children. Comparisons between children with a CI and NH were made against a subset of 21 of the children with NH who were matched to children with CIs by age, gender, socioeconomic background, and musical activity. Regression analyses, run separately for children with CIs and NH, assessed how much variance in each language task was shared with each of prosodic perception, the child's own music activity, and activities with parents, including singing and reading. All statistical analyses were conducted both with and without control for age and maternal education.

RESULTS

Musically active children with CIs performed similarly to NH controls in all language tasks, while those who were not musically active performed more poorly. Only musically nonactive children with CIs made more phonological and semantic errors in word finding than NH controls, and word finding correlated with other language skills. Regression analysis results for word finding and VIQ were similar for children with CIs and NH. These language skills shared considerable variance with the perception of prosodic stress and musical activities. When age and maternal education were controlled for, strong links remained between perception of prosodic stress and VIQ (shared variance: CI, 32%/NH, 16%) and between musical activities and word finding (shared variance: CI, 53%/NH, 20%). Links were always stronger for children with CIs, for whom better phonological awareness was also linked to improved stress perception and more musical activity, and parental activities altogether shared significantly variance with word finding and VIQ.

CONCLUSIONS

For children with CIs and NH, better perception of prosodic stress and musical activities with singing are associated with improved generative language skills. In addition, for children with CIs, parental singing has a stronger positive association to word finding and VIQ than parental reading. These results cannot address causality, but they suggest that good perception of prosodic stress, musical activities involving singing, and parental singing and reading may all be beneficial for word finding and other generative language skills in implanted children.

Effects of Prosody Rehabilitation on Acoustic Analysis of Prosodic Features in Hearing-Impaired Children: A Randomized Controlled Trial

BACKGROUND

The role of prosody in language acquisition and effective communication is documented in research. Nevertheless, rehabilitation of prosodic skills in children with hearing impairment using hearing aids or cochlear implants is relatively neglected compared to other speech and language areas.

OBJECTIVE

To detect the effect of prosodic rehabilitation using the adapted translated version of the "Prosody Treatment Program" on expression of prosodic features in Egyptian Arabic-speaking hearing-impaired school-age children fitted with hearing aids or cochlear implant devices in comparison to conventional auditory and language rehabilitation.

METHODS

This study was conducted on 34 children with sensorineural hearing loss in a randomized controlled trial design. Children were randomly divided into 2 groups, group A (cases) and group B (control), by block randomization. Both groups were initially evaluated for their prosodic skills using objective measures. Group A received rehabilitation for prosody using the Prosody Treatment Program for 1 h, once per week for 3 months, while group B received conventional auditory and language training and served as their control. Both groups were re-evaluated using the same protocol after 3 months of therapy.

RESULTS

A statistically significant improvement of most of the assessed prosodic parameters in group A was shown when comparing the pretherapy and posttherapy scores, as well as comparing between both studied groups after therapy.

CONCLUSIONS

Prosody is amenable to motor learning. The Prosody Treatment Program seems to be an effective rehabilitation tool in improving some prosodic skills of hearing-impaired children. Prosodic rehabilitation showed superiority to conventional auditory and language training in improving the expression of some prosodic features and pragmatic language skills.

Spoken Language Skills in Children With Bilateral Hearing Aids or Bilateral Cochlear Implants at the Age of Three Years

Early hearing aid (HA) fitting and cochlear implants (CIs) aim to reduce the effects of hearing loss (HL) on spoken language development. The goals of this study were (1) to examine spoken language skills of children with bilateral HAs and children with bilateral CIs; (2) to compare their language skills to the age-norms of peers with normal hearing (NH); and (3) to investigate factors associated with spoken language outcomes.

Listening Difficulties of Children With Cochlear Implants in Mainstream Secondary Education

OBJECTIVES

Previous research has shown that children with cochlear implants (CIs) encounter more communication difficulties than their normal-hearing (NH) peers in kindergarten and elementary schools. Yet, little is known about the potential listening difficulties that children with CIs may experience during secondary education. The aim of this study was to investigate the listening difficulties of children with a CI in mainstream secondary education and to compare these results to the difficulties of their NH peers and the difficulties observed by their teachers.

DESIGN

The Dutch version of the Listening Inventory for Education Revised (LIFE-R) was administered to 19 children (mean age = 13 years 9 months; SD = 9 months) who received a CI early in life, to their NH classmates (n = 239), and to their teachers (n = 18). All participants were enrolled in mainstream secondary education in Flanders (first to fourth grades). The Listening Inventory for Secondary Education consists of 15 typical listening situations as experienced by students (LIFEstudent) during class activities (LIFEclass) and during social activities at school (LIFEsocial). The teachers completed a separate version of the Listening Inventory for Secondary Education (LIFEteacher) and Screening Instrument for Targeting Educational Risk.

RESULTS

Participants with CIs reported significantly more listening difficulties than their NH peers. A regression model estimated that 75% of the participants with CIs were at risk of experiencing listening difficulties. The chances of experiencing listening difficulties were significantly higher in participants with CIs for 7 out of 15 listening situations. The 3 listening situations that had the highest chance of resulting in listening difficulties were (1) listening during group work, (2) listening to multimedia, and (3) listening in large-sized classrooms. Results of the teacher's questionnaires (LIFEteacher and Screening Instrument for Targeting Educational Risk) did not show a similar significant difference in listening difficulties between participants with a CI and their NH peers. According to teachers, NH participants even obtained significantly lower scores for staying on task and for participation in class than participants with a CI.

CONCLUSIONS

Although children with a CI seemingly fit in well in mainstream schools, they still experience significantly more listening difficulties than their NH peers. Low signal to noise ratios (SNRs), distortions of the speech signal (multimedia, reverberation), distance, lack of visual support, and directivity effects of the microphones were identified as difficulties for children with a CI in the classroom. As teachers may not always notice these listening difficulties, a list of practical recommendations was provided in this study, to raise awareness among teachers and to minimize the difficulties.

Spatial Hearing Difficulties in Reaching Space in Bilateral Cochlear Implant Children Improve With Head Movements

Supplemental Digital Content is available in the text.

The aim of this study was to assess three-dimensional (3D) spatial hearing abilities in reaching space of children and adolescents fitted with bilateral cochlear implants (BCI). The study also investigated the impact of spontaneous head movements on sound localization abilities.

The Perception of Regional Dialects and Foreign Accents by Cochlear Implant Users

Purpose This preliminary research examined (a) the perception of two common sources of indexical variability in speech-regional dialects and foreign accents, and (b) the relation between indexical processing and sentence recognition among prelingually deaf, long-term cochlear implant (CI) users and normal-hearing (NH) peers. Method Forty-three prelingually deaf adolescent and adult CI users and 44 NH peers completed a regional dialect categorization task, which consisted of identifying the region of origin of an unfamiliar talker from six dialect regions of the United States. They also completed an intelligibility rating task, which consisted of rating the intelligibility of short sentences produced by native and nonnative (foreign-accented) speakers of American English on a scale from 1 (not intelligible at all) to 7 (very intelligible). Individual performance was compared to demographic factors and sentence recognition scores. Results Both CI and NH groups demonstrated difficulty with regional dialect categorization, but NH listeners significantly outperformed the CI users. In the intelligibility rating task, both CI and NH listeners rated foreign-accented sentences as less intelligible than native sentences; however, CI users perceived smaller differences in intelligibility between native and foreign-accented sentences. Sensitivity to accent differences was related to sentence recognition accuracy in CI users. Conclusions Prelingually deaf, long-term CI users are sensitive to accent variability in speech, but less so than NH peers. Additionally, individual differences in CI users' sensitivity to indexical variability was related to sentence recognition abilities, suggesting a common source of difficulty in the perception and encoding of fine acoustic-phonetic details in speech.

Cochlear Implantation in Infants: Why and How

In children with congenital deafness, cochlear implantation (CI) prior to 12 months of age offers the opportunity to foster more typical auditory development during late infancy and early childhood. Recent studies have found a positive association between early implantation and expressive and receptive language outcomes, with some children able to achieve normal language skills by the time of school entry. Universal newborn hearing screening improved early detection and diagnosis of congenital hearing loss, allowing for earlier intervention, including decision-making regarding cochlear implant (CI) candidacy. It can be more challenging to confirm CI candidacy in infants; therefore, a multidisciplinary approach, including objective audiometric testing, is recommended to not only confirm the diagnosis but also to counsel families regarding expectations and long-term management. Surgeons performing CI surgery in young children should consider both the anesthetic risks of surgery in infancy and the ways in which mastoid anatomy may differ between infants and older children or adults. Multiple studies have found CI surgery in infants can be performed safely and effectively. This article reviews current evidence regarding indications for implantation in children younger than 12 months of age and discusses perioperative considerations and surgical technique.

Bimodal Benefits Revealed by Categorical Perception of Lexical Tones in Mandarin-Speaking Kindergarteners With a Cochlear Implant and a Contralateral Hearing Aid

Purpose Pitch reception poses challenges for individuals with cochlear implants (CIs), and adding a hearing aid (HA) in the nonimplanted ear is potentially beneficial. The current study used fine-scale synthetic speech stimuli to investigate the bimodal benefit for lexical tone categorization in Mandarin-speaking kindergarteners using a CI and an HA in opposite ears. Method The data were collected from 16 participants who were required to complete two classical tasks for speech categorical perception (CP) with CI + HA device condition and CI alone condition. Linear mixed-effects models were constructed to evaluate the identification and discrimination scores across different device conditions. Results The bimodal kindergarteners showed CP for the continuum varying from Mandarin Tone 1 and Tone 2. Moreover, the additional acoustic information from the contralateral HA contributes to improved lexical tone categorization, with a steeper slope, a higher discrimination score of between-category stimuli pair, and an improved peakedness score (i.e., an increased benefit magnitude for discriminations of between-category over within-category pairs) for the CI + HA condition than the CI alone condition. The bimodal kindergarteners with better residual hearing thresholds at 250 Hz level in the nonimplanted ear could perceive lexical tones more categorically. Conclusion The enhanced CP results with bimodal listening provide clear evidence for the clinical practice to fit a contralateral HA in the nonimplanted ear in kindergarteners with unilateral CIs with direct benefits from the low-frequency acoustic hearing.

Age-Related Changes in Listening Effort for Children and Teenagers With Normal Hearing and Cochlear Implants

OBJECTIVES

A clinically viable measure of listening effort is crucial in safeguarding the educational success of hard-of-hearing students enrolled in mainstream schools. To this end, a novel behavioral paradigm of listening effort targeting school-age children has been designed and reported in Hsu et al. (2017). The current article consists of two follow-up experiments investigating the effects of noise, processing depth, and age in a similar paradigm, first in a group of participants with normal hearing (NH) followed by a sample of school-age cochlear implant (CI) users. Research objectives include the construction of normative values of listening effort and comparing outcomes between age-matched NH and CI participants.

DESIGN

In Experiment 1, the listening effort dual-task paradigm was evaluated in a group of 90 NH participants with roughly even age distribution between 6 and 26 years. The primary task asked a participant to verbally repeat each of the target words presented in either quiet or noise, while the secondary task consisted of categorization true-or-false questions "animal" and "dangerous," representing two levels of semantic processing depth. Two outcome measures were obtained for each condition: a classic word recognition score (WRS) and an average response time (RT) measured during the secondary task. The RT was defined as the main listening effort metric throughout the study. Each NH participant's long-term memory retrieval speed and working memory capacity were also assessed through standardized tests. It was hypothesized that adding noise would negatively affect both WRS and RT, whereas an increase in age would see significant improvement in both measures. A subsequent Experiment 2 administered a shortened version of the paradigm to 14 school-age CI users between 5 and 14 years old at a university clinic. The patterns of results from the CI group were expected to approximate those of the NH group, except with larger between-subject variability.

RESULTS

For NH participants, while WRS was significantly affected by age and noise levels, RT was significantly affected by age, noise levels, and depth of processing. RT was significantly correlated with long-term memory retrieval speed but not with working memory capacity. There was also a significant interaction effect between age and noise levels for both WRS and RT. The RT data set from the NH group served as a basis to establish age-dependent 95% prediction intervals for expected future observations. For CI participants, the effect of age on the two outcome measures was more visible when target words were presented in quiet. Depending on the condition, between 35.7% and 72.7% of the children with CI exhibited higher-than-norms listening effort as measured by categorization processing times.

CONCLUSION

Listening effort appears to decrease with age from early school-age years to late teenage years. The effects of background noise and processing depth are comparable with those reported in Hsu et al. (2017). Future studies interested in expanding the paradigm's clinical viability should focus on the reduction of testing time while maintaining or increasing the sensitivity and external validity of its outcome measures.

Rhythmic Abilities of Children With Hearing Loss

OBJECTIVES

Children with hearing loss (HL), in spite of early cochlear implantation, often struggle considerably with language acquisition. Previous research has shown a benefit of rhythmic training on linguistic skills in children with HL, suggesting that improving rhythmic capacities could help attenuating language difficulties. However, little is known about general rhythmic skills of children with HL and how they relate to speech perception. The aim of this study is twofold: (1) to assess the abilities of children with HL in different rhythmic sensorimotor synchronization tasks compared to a normal-hearing control group and (2) to investigate a possible relation between sensorimotor synchronization abilities and speech perception abilities in children with HL.

DESIGN

A battery of sensorimotor synchronization tests with stimuli of varying acoustic and temporal complexity was used: a metronome, different musical excerpts, and complex rhythmic patterns. Synchronization abilities were assessed in 32 children (aged from 5 to 10 years) with a severe to profound HL mainly fitted with one or two cochlear implants (n = 28) or with hearing aids (n = 4). Working memory and sentence repetition abilities were also assessed. Performance was compared to an age-matched control group of 24 children with normal hearing. The comparison took into account variability in working memory capacities. For children with HL only, we computed linear regressions on speech, sensorimotor synchronization, and working memory abilities, including device-related variables such as onset of device use, type of device, and duration of use.

RESULTS

Compared to the normal-hearing group, children with HL performed poorly in all sensorimotor synchronization tasks, but the effect size was greater for complex as compared to simple stimuli. Group differences in working memory did not explain this result. Linear regression analysis revealed that working memory, synchronization to complex rhythms performances, age, and duration of device use predicted the number of correct syllables produced in a sentence repetition task.

CONCLUSION

Despite early cochlear implantation or hearing aid use, hearing impairment affects the quality of temporal processing of acoustic stimuli in congenitally deaf children. This deficit seems to be more severe with stimuli of increasing rhythmic complexity highlighting a difficulty in structuring sounds according to a temporal hierarchy.

Comparison of Expressive Spoken Language Skills in Children With Cochlear Implants and Children With Typical Hearing

When children start formal education, they are expected to be able to express complex thoughts. However, in order to do so, they need to be able to use both complex grammatical structures and a variety of words. One group that is at risk of having a delay in terms of their expressive language ability is children with cochlear implants (CI). In this study, we evaluated whether children with CI perform comparably to children with typical hearing (TH) on a standard expressive spoken grammar and a standard expressive spoken vocabulary task when the groups were matched on non-verbal intelligence and working memory capacity. It was found that the children with CI in this study performed more poorly on a standard expressive spoken vocabulary task but not on a standard expressive spoken grammar task when compared to the children with TH. Differences in terms of expressive spoken vocabulary do not seem to be explained by differences in cognitive ability. In addition, the variation in terms of expressive spoken language ability was larger in the children with CI compared to the children with TH. This might be explained by additional confounding factors, like the time of language deprivation or by a greater influence of cognitive differences for the acquisition of spoken language for children with CI.

Listening in Noise Remains a Significant Challenge for Cochlear Implant Users: Evidence from Early Deafened and Those with Progressive Hearing Loss Compared to Peers with Normal Hearing

Cochlear implants (CIs) are the state-of-the-art therapy for individuals with severe to profound hearing loss, providing them with good functional hearing. Nevertheless, speech understanding in background noise remains a significant challenge. The purposes of this study were to: (1) conduct a novel within-study comparison of speech-in-noise performance across ages in different populations of CI and normal hearing (NH) listeners using an adaptive sentence-in-noise test, and (2) examine the relative contribution of sensory information and cognitive–linguistic factors to performance. Forty CI users (mean age 20 years) were divided into “early-implanted” <4 years (n = 16) and “late-implanted” >6 years (n = 11), all prelingually deafened, and “progressively deafened” (n = 13). The control group comprised 136 NH subjects (80 children, 56 adults). Testing included the Hebrew Matrix test, word recognition in quiet, and linguistic and cognitive tests. Results show poorer performance in noise for CI users across populations and ages compared to NH peers, and age at implantation and word recognition in quiet were found to be contributing factors. For those recognizing 50% or more of the words in quiet (n = 27), non-verbal intelligence and receptive vocabulary explained 63% of the variance in noise. This information helps delineate the relative contribution of top-down and bottom-up skills for speech recognition in noise and can help set expectations in CI counseling.

Bimodal Benefits for Lexical Tone Recognition: An Investigation on Mandarin-speaking Preschoolers with a Cochlear Implant and a Contralateral Hearing Aid

Pitch perception is known to be difficult for individuals with cochlear implant (CI), and adding a hearing aid (HA) in the non-implanted ear is potentially beneficial. The current study aimed to investigate the bimodal benefit for lexical tone recognition in Mandarin-speaking preschoolers using a CI and an HA in opposite ears. The child participants were required to complete tone identification in quiet and in noise with CI + HA in comparison with CI alone. While the bimodal listeners showed confusion between Tone 2 and Tone 3 in recognition, the additional acoustic information from the contralateral HA alleviated confusion between these two tones in quiet. Moreover, significant improvement was demonstrated in the CI + HA condition over the CI alone condition in noise. The bimodal benefit for individual subjects could be predicted by the low-frequency hearing threshold of the non-implanted ear and the duration of bimodal use. The findings support the clinical practice to fit a contralateral HA in the non-implanted ear for the potential benefit in Mandarin tone recognition in CI children. The limitations call for further studies on auditory plasticity on an individual basis to gain insights on the contributing factors to the bimodal benefit or its absence.

Role of Targeted Next Generation Sequencing in the Etiological Work-Up of Congenitally Deaf Children

OBJECTIVES

The purpose of this study is to report the results of a comprehensive etiological work-up for congenitally deaf children including targeted next generation sequencing.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Fifty children with congenital, bilateral profound hearing loss (HL) (>90 dBnHL).

INTERVENTIONS

Etiological work-up included testing for pathogenic variants in GJB2, a phenotype driven genetic analysis, screening for congenital infections and imaging. When no etiology could be found, comprehensive genetic testing was performed using a HL gene panel including 45 syndromic and 96 non-syndromic HL genes.

RESULTS

Eleven patients carried bi-allelic pathogenic variants in GJB2. Phenotype driven genetic analysis identified two homozygous KCNQ1 patients (Jervell and Lange Nielsen syndrome) and one heterozygous CHD7 patient (CHARGE syndrome). One patient was diagnosed with achondroplasia and one had a clinical diagnosis of Waardenburg syndrome. A deafness gene panel evaluated 16 patients. In 12 out of 16, we identified a pathogenic (n = 12) or likely pathogenic (n = 2) variant and one variant of unknown significance (VUS). A definite diagnosis of non-syndromic or syndromic HL was made in 18 and seven patients, respectively. Non-genetic causes were congenital cytomegalovirus infection (n = 11), anatomic abnormalities (n = 2), neurological/metabolic/polymalformative conditions (n = 3), meningitis (n = 1), and auditory neuropathy (n = 1).

CONCLUSIONS

A definite genetic cause was found in 25 (50%) of congenital, bilaterally deaf children. Our data show that implementation of a gene panel improves the diagnostic yield for etiological work-up of congenital profound HL to 86%. Identification of the etiology of congenital HL may contribute to predicting outcomes of cochlear implantation.

Spatial Release From Masking in 2-Year-Olds With Normal Hearing and With Bilateral Cochlear Implants

This study evaluated spatial release from masking (SRM) in 2- to 3-year-old children who are deaf and were implanted with bilateral cochlear implants (BiCIs), and in age-matched normal-hearing (NH) toddlers. Here, we examined whether early activation of bilateral hearing has the potential to promote SRM that is similar to age-matched NH children. Listeners were 13 NH toddlers and 13 toddlers with BiCIs, ages 27 to 36 months. Speech reception thresholds (SRTs) were measured for target speech in front (0°) and for competitors that were either Colocated in front (0°) or Separated toward the right (+90°). SRM was computed as the difference between SRTs in the front versus in the asymmetrical condition. Results show that SRTs were higher in the BiCI than NH group in all conditions. Both groups had higher SRTs in the Colocated and Separated conditions compared with Quiet, indicating masking. SRM was significant only in the NH group. In the BiCI group, the group effect of SRM was not significant, likely limited by the small sample size; however, all but two children had SRM values within the NH range. This work shows that to some extent, the ability to use spatial cues for source segregation develops by age 2 to 3 in NH children and is attainable in most of the children in the BiCI group. There is potential for the paradigm used here to be used in clinical settings to evaluate outcomes of bilateral hearing in very young children.

Which Questions Do Children With Cochlear Implants Understand? An Eye-Tracking Study

Purpose The purpose of this study was to investigate the processing of morphosyntactic cues (case and verb agreement) by children with cochlear implants (CIs) in German which-questions, where interpretation depends on these morphosyntactic cues. The aim was to examine whether children with CIs who perceive the different cues also make use of them in speech comprehension and processing in the same way as children with normal hearing (NH). Method Thirty-three children with CIs (age 7;01-12;04 years;months, M = 9;07, bilaterally implanted before age 3;3) and 36 children with NH (age 7;05-10;09 years, M = 9;01) received a picture selection task with eye tracking to test their comprehension of subject, object, and passive which-questions. Two screening tasks tested their auditory discrimination of case morphology and their perception and comprehension of subject-verb agreement. Results Children with CIs who performed well on the screening tests still showed more difficulty on the comprehension of object questions than children with NH, whereas they comprehended subject questions and passive questions equally well as children with NH. There was large interindividual variability within the CI group. The gaze patterns of children with NH showed reanalysis effects for object questions disambiguated later in the sentence by verb agreement, but not for object questions disambiguated by case at the first noun phrase. The gaze patterns of children with CIs showed reanalysis effects even for object questions disambiguated at the first noun phrase. Conclusions Even when children with CIs perceive case and subject-verb agreement, their ability to use these cues for offline comprehension and online processing still lags behind normal development, which is reflected in lower performance rates and longer processing times. Individual variability within the CI group can partly be explained by working memory and hearing age. Supplemental Material https://doi.org/10.23641/asha.7728731.

Parent–Child Interaction Therapy as a Behavior and Spoken Language Intervention for Young Children With Hearing Loss

Purpose

The importance of early intervention for fostering language in children with hearing loss has been well documented; those that facilitate parent engagement are particularly effective. Listening and spoken language outcomes among children with hearing loss continue to fall short compared to hearing peers, despite improvements in hearing technologies. The current study evaluated the effectiveness of parent–child interaction therapy (PCIT) as a behavioral intervention for children with hearing loss and its applicability as a language intervention.

Method

PCIT effectiveness was evaluated for children with hearing loss (PCIT treatment group: N = 18). For a subset of the treatment group (matched experimental group: n = 6), pretreatment and posttreatment language samples were compared to a matched control group ( n = 6).

Results

Significant changes were observed in parent skills and child behavior from pretreatment to posttreatment for the PCIT treatment group. A subset of the treatment group (matched experimental group) with available matched controls (matched control group) demonstrated a significant increase in utterances and a trend toward significant increase in receptive vocabulary compared to the control group.

Conclusion

PCIT is a promising intervention for children with hearing loss that empowers parents to engage in optimal indirect language stimulation, improves parent–child interactions, improves child behavior, and promotes spoken language skills.

Basic Measures of Prosody in Spontaneous Speech of Children With Early and Late Cochlear Implantation

PURPOSE

Relative to normally hearing (NH) peers, the speech of children with cochlear implants (CIs) has been found to have deviations such as a high fundamental frequency, elevated jitter and shimmer, and inadequate intonation. However, two important dimensions of prosody (temporal and spectral) have not been systematically investigated. Given that, in general, the resolution in CI hearing is best for the temporal dimension and worst for the spectral dimension, we expected this hierarchy to be reflected in the amount of CI speech's deviation from NH speech. Deviations, however, were expected to diminish with increasing device experience.

METHOD

Of 9 Dutch early- and late-implanted (division at 2 years of age) children and 12 hearing age-matched NH controls, spontaneous speech was recorded at 18, 24, and 30 months after implantation (CI) or birth (NH). Six spectral and temporal outcome measures were compared between groups, sessions, and genders.

RESULTS

On most measures, interactions of Group and/or Gender with Session were significant. For CI recipients as compared with controls, performance on temporal measures was not in general more deviant than spectral measures, although differences were found for individual measures. The late-implanted group had a tendency to be closer to the NH group than the early-implanted group. Groups converged over time.

CONCLUSIONS

Results did not support the phonetic dimension hierarchy hypothesis, suggesting that the appropriateness of the production of basic prosodic measures does not depend on auditory resolution. Rather, it seems to depend on the amount of control necessary for speech production.

Parents' Perception of Health-Related Quality of Life in Children With Cochlear Implants: The Impact of Language Skills and Hearing

PURPOSE

The study compared how parents of children with cochlear implants (CIs) and parents of children with normal hearing perceive their children's health-related quality of life (HR-QOL).

METHOD

The sample consisted of 186 Norwegian-speaking children in the age span of 5;0-12;11 (years;months): 106 children with CIs (53% boys, 47% girls) and 80 children with normal hearing (44% boys, 56% girls). No children had known additional disabilities affecting language, cognitive development, or HR-QOL. Parents completed the generic questionnaire Pediatric Quality of Life Inventory (Varni, Seid, & Kurtin, 2001), whereas children completed a test battery measuring different aspects of language and hearing.

RESULTS

Parents of children with CIs reported statistically significantly poorer HR-QOL in their children, on Pediatric Quality of Life Inventory total score and the subdomains social functioning and school functioning. Roughly 50% of parents of children with CIs reported HR-QOL levels (total score) within normal limits. No significant differences between groups emerged on the physical health and emotional functioning subscales. For the children in the group with CIs, better speech perception in everyday situations was associated with higher proxy-ratings of HR-QOL. Better spoken language skills were weakly to moderately associated with higher HR-QOL.

CONCLUSIONS

The findings suggest that the social and school situation is not yet resolved satisfactorily for children with CIs. Habilitation focusing on spoken language skills and better sound environment may improve social interactions with peers and overall school functioning.

Development of perception and perceptual learning for multi-timescale filtered speech

The perception of temporally changing auditory signals has a gradual developmental trajectory. Speech is a time-varying signal, and slow changes in speech (filtered at 0-4 Hz) are preferentially processed by the right hemisphere, while the left extracts faster changes (filtered at 22-40 Hz). This work examined the ability of 8- to 19-year-olds to both perceive and learn to perceive filtered speech presented diotically for each filter type (low vs high) and dichotically for preferred or non-preferred laterality. Across conditions, performance improved with increasing age, indicating that the ability to perceive filtered speech continues to develop into adolescence. Across age, performance was best when both bands were presented dichotically, but with no benefit for presentation to the preferred hemisphere. Listeners thus integrated slow and fast transitions between the two ears, benefitting from more signal information, but not in a hemisphere-specific manner. After accounting for potential ceiling effects, learning was greatest when both bands were presented dichotically. These results do not support the idea that cochlear implants could be improved by providing differentially filtered information to each ear. Listeners who started with poorer performance learned more, a factor which could contribute to the positive cochlear implant outcomes typically seen in younger children.

Spoken and Written Narrative in Persian-Speaking Students Who Received Cochlear Implant and/or Hearing Aid

OBJECTIVES

To compare narrative skills between fourth and fifth grades of Persian-speaking students with hearing impairments and typical hearing students of the same grade and also to evaluate the effects of group, sex, hearing age, and educational grade of the students on their spoken/written narrative performance.

METHODS

The subjects were 174 students aged 10-13 years, 54 of whom wore cochlear implants, 60 suffered from moderate to severe hearing losses and wore hearing aids, with the remaining 60 students being typical hearing in terms of the sense of hearing. The micro- and macrostructure components of spoken and written narrative were elicited from a pictorial story (The Playful Little Elephant) and then scored by raters.

RESULTS

Compared to the typical hearing, the students with hearing impairments had significantly lower scores in all of the microstructure components of narratives. However, the findings showed no significant difference among different groups in macrostructure components of narratives. It was also revealed that the students had equal performance in spoken and written narrative. Finally, factor analysis manifested that group, sex, hearing age, and educational level of children might alter the outcome measures in various interactions.

CONCLUSION

Although cochlear implantation was more effective than hearing aid on spoken and written narrative skills, the Persian-speaking students with hearing impairments were seen to need additional trainings on microstructure components of spoken/written narrative.

Working Memory for Linguistic and Non-linguistic Manual Gestures: Evidence, Theory, and Application

Linguistic manual gestures are the basis of sign languages used by deaf individuals. Working memory and language processing are intimately connected and thus when language is gesture-based, it is important to understand related working memory mechanisms. This article reviews work on working memory for linguistic and non-linguistic manual gestures and discusses theoretical and applied implications. Empirical evidence shows that there are effects of load and stimulus degradation on working memory for manual gestures. These effects are similar to those found for working memory for speech-based language. Further, there are effects of pre-existing linguistic representation that are partially similar across language modalities. But above all, deaf signers score higher than hearing non-signers on an n-back task with sign-based stimuli, irrespective of their semantic and phonological content, but not with non-linguistic manual actions. This pattern may be partially explained by recent findings relating to cross-modal plasticity in deaf individuals. It suggests that in linguistic gesture-based working memory, semantic aspects may outweigh phonological aspects when processing takes place under challenging conditions. The close association between working memory and language development should be taken into account in understanding and alleviating the challenges faced by deaf children growing up with cochlear implants as well as other clinical populations.

Listening Effort Through Depth of Processing in School-Age Children

OBJECTIVES

A reliable and practical measure of listening effort is crucial in the aural rehabilitation of children with communication disorders. In this article, we propose a novel behavioral paradigm designed to measure listening effort in school-age children based on different depths and levels of verbal processing. The paradigm consists of a classic word recognition task performed in quiet and in noise coupled to one of three additional tasks asking the children to judge the color of simple pictures or a certain semantic category of the presented words. The response time (RT) from the categorization tasks is considered the primary indicator of listening effort.

DESIGN

The listening effort paradigm was evaluated in a group of 31 normal-hearing, normal-developing children 7 to 12 years of age. A total of 146 Dutch nouns were selected for the experiment after surveying 14 local Dutch-speaking children. Windows-based custom software was developed to administer the behavioral paradigm from a conventional laptop computer. A separate touch screen was used as a response interface to gather the RT data from the participants. Verbal repetition of each presented word was scored by the tester and a percentage-correct word recognition score (WRS) was calculated for each condition. Randomized lists of target words were presented in one of three signal to noise ratios (SNR) to examine the effect of background noise on the two outcome measures of WRS and RT. Three novel categorization tasks, each corresponding to a different depth or elaboration level of semantic processing, were developed to examine the effect of processing level on either WRS or RT. It was hypothesized that, while listening effort as measured by RT would be affected by both noise and processing level, WRS performance would be affected by changes in noise level only. The RT measure was also hypothesized to increase more from an increase in noise level in categorization conditions demanding a deeper or more elaborate form of semantic processing.

RESULTS

There was a significant effect of SNR level on school-age children's WRS: their word recognition performance tended to decrease with increasing background noise level. However, depth of processing did not seem to affect WRS. Moreover, a repeated-measure analysis of variance fitted to transformed RT data revealed that this measure of listening effort in normal-hearing school-age children was significantly affected by both SNR level and the depth of semantic processing. There was no significant interaction between noise level and the type of categorization task with regard to RT.

CONCLUSIONS

The observed patterns of WRS and RT supported the hypotheses regarding the effects of background noise and depth of processing on word recognition performance and a behavioral measure of listening effort. The magnitude of noise-induced change in RT did not differ between categorization tasks, however. Our findings point to future research directions regarding the potential effects of age, working memory capacity, and cross-modality interaction when measuring listening effort in different levels of semantic processing.

Language development in the pediatric cochlear implant patient

Objective

To access the long-term outcomes of children implanted during most sensitive period for language development.

Study design

Literature review.

Method

An initial PubMed search was carried out using the search terms language development and cochlear implant resulted in 1149 citations. A second search was carried out on the initial citations using the criterion of implantation in the period of birth to 24 months, which identified 386 articles. These were analyzed to determine those studies in which linguistic outcome was measured at least three or more years following implantation.

Results

Twenty-one reports published from 2004 to 2017 that met the criteria. The range of follow-up was from 3 years to an excess of 10 years. Four => 10-year follow-up reports were consistent in showing that the earlier the subject is implanted the better the outcome. Many, but not all, of these children did obtain age-appropriate language. There were 17 reports with follow-up from 3 to less than 10 years. In 7 of the 11 studies, the children's expressive language was reported to have reached an age level of less than 80%. The results for receptive language showed that 4 of the 11 studies found that the children achieved a receptive language age level of less than 80%. There were 8 studies which documented the effect of implantation before 12 months of age and between 12 and 24 months of age and they all found that the earlier the implantation, the better the outcome for language.

Conclusion

The cochlear implant is efficacious in the amelioration of receptive and expressive language deficits in most congenitally deafened children implanted before the age of one. The language outcomes for those implanted after the age of one decline as the age of implantation increases.

Level of Evidence

N/A.

Comprehension of Degraded Speech Matures During Adolescence

PURPOSE

The aim of the study was to compare comprehension of spectrally degraded (noise-vocoded [NV]) speech and perceptual learning of NV speech between adolescents and young adults and examine the role of phonological processing and executive functions in this perception.

METHOD

Sixteen younger adolescents (11-13 years), 16 older adolescents (14-16 years), and 16 young adults (18-22 years) listened to 40 NV sentences and repeated back what they heard. They also completed tests assessing phonological processing and a variety of executive functions.

RESULTS

Word-report scores were generally poorer for younger adolescents than for the older age groups. Phonological processing also predicted initial word-report scores. Learning (i.e., improvement across training times) did not differ with age. Starting performance and processing speed predicted learning, with greater learning for those who started with the lowest scores and those with faster processing speed.

CONCLUSIONS

Degraded (NV) speech comprehension is not mature even by early adolescence; however, like adults, adolescents are able to improve their comprehension of degraded speech with training. Thus, although adolescents may have initial difficulty in understanding degraded speech or speech as presented through hearing aids or cochlear implants, they are able to improve their perception with experience. Processing speed and phonological processing may play a role in degraded speech comprehension in these age groups.

Development and validation of the Nottingham Auditory Milestones (NAMES) profile for deaf children under 2 years old, using cochlear implants

OBJECTIVES

Clinicians face considerable challenges in setting appropriate auditory goals for babies and young children who receive cochlear implants. This paper describes the rationale, organization, implementation, and validation of the Nottingham Auditory Milestones profile that was developed to address these challenges.

METHODS

The use of the profile has been fully integrated into the postoperative pathway at the Nottingham Auditory Implant Programme since 2009. Data are presented on a cohort of 30 children who received bilateral cochlear implants under the age of 2 years and who have no other diagnosed difficulties. The data were used to validate the profile's structure and characterize the expected development trajectory for this population of children.

RESULTS

The analysis of routine data from the children confirmed that the profile's structure reflected the typical order and rate at which skills emerged and were acquired over the first 3 years following cochlear implantation. The distribution of profile scores across five assessment time-points established a developmental trajectory for typically developing children. Three case studies describe the use of the profile to set consistent expectations for progress for a wide range of children.

DISCUSSION

The development trajectory established using the profile provides a mechanism to identify children not making the expected progress, in order to support the need for a review of approach or a differential diagnosis.

CONCLUSION

The Nottingham Auditory Milestones profile is an accessible and practical tool for identifying, monitoring, and appraising the auditory achievements of deaf babies and young children in the first 3 years following cochlear implantation.

Assessment of narrative writing by Persian-speaking students with hearing impairments

OBJECTIVE

Previous studies have highlighted that narrative skill is critical to the development of the literacy skills by children. Children with cochlear implants (CI) and hearing aids (HA) may have problems in narrative development compared to peers with healthy hearing (HH). There is no exact data about the narrative writing ability of Persian-speaking students who are hearing-impaired. This study was undertaken to compare the microstructure and macrostructure scores for narrative writing of Persian-speaking students who are hearing-impaired and peers with HH.

DESIGN

This was a cross-sectional descriptive-analytical study.

SETTING

The subjects were recruited from elementary schools in the city of Tehran.

PARTICIPANTS

A total of 144 elementary school students were participated.

OUTCOME MEASURES

The written narratives were elicited using a wordless pictorial storybook story. Three-way ANOVA with post hoc adjusted Bonferroni test was applied to determine the main effects and interactions of grounded variables on the microstructure and macrostructure components of narrative writing.

RESULTS

No significant differences were observed in the macrostructure components of narrative writing between hearing-impaired and HH students. Factors analysis showed that the 4th grade HH students had significantly the highest scores, and the 3rd grade HA students had significantly the lowest scores in microstructure components of narrative writing.

CONCLUSION

The findings revealed that hearing-impaired students similarly to their HH peers can transmit the main idea (macrostructure) of narrative writing, but show critical difficulties when using complete grammatical elements (microstructures) to form sentences to convey the idea in the narrative.

Auditory Environment Across the Life Span of Cochlear Implant Users: Insights From Data Logging

PURPOSE

We describe the natural auditory environment of people with cochlear implants (CIs), how it changes across the life span, and how it varies between individuals.

METHOD

We performed a retrospective cross-sectional analysis of Cochlear Nucleus 6 CI sound-processor data logs. The logs were obtained from 1,501 people with CIs (ages 0-96 years). They covered over 2.4 million hr of implant use and indicated how much time the CI users had spent in various acoustical environments. We investigated exposure to spoken language, noise, music, and quiet, and analyzed variation between age groups, users, and countries.

RESULTS

CI users spent a substantial part of their daily life in noisy environments. As a consequence, most speech was presented in background noise. We found significant differences between age groups for all auditory scenes. Yet even within the same age group and country, variability between individuals was substantial.

CONCLUSIONS

Regardless of their age, people with CIs face challenging acoustical environments in their daily life. Our results underline the importance of supporting them with assistive listening technology. Moreover, we found large differences between individuals' auditory diets that might contribute to differences in rehabilitation outcomes. Their causes and effects should be investigated further.

Audio-visual speech perception in noise: Implanted children and young adults versus normal hearing peers

OBJECTIVE

The purpose of the current study was to evaluate auditory, visual and audiovisual speech perception abilities among two groups of cochlear implant (CI) users: prelingual children and long-term young adults, as compared to their normal hearing (NH) peers.

METHODS

Prospective cohort study that included 50 participants, divided into two groups of CI (10 children and 10 adults), and two groups of normal hearing peers (15 participants each). Speech stimuli included monosyllabic meaningful and nonsense words in a signal to noise ratio of 0 dB. Speech stimuli were introduced via auditory, visual and audiovisual modalities.

RESULTS

(1) CI children and adults show lower speech perception accuracy with background noise in audiovisual and auditory modalities, as compared to NH peers, but significantly higher visual speech perception scores. (2) CI children are superior to CI adults in speech perception in noise via auditory modality, but inferior in the visual one. Both CI children and CI adults had similar audiovisual integration.

CONCLUSIONS

The findings of the current study show that in spite of the fact that the CI children were implanted bilaterally, at a very young age, and using advanced technology, they still have difficulties in perceiving speech in adverse listening conditions even when adding the visual modality. This suggests that adding audiovisual training might be beneficial for this group by improving their audiovisual integration in difficult listening situations.