Disproportionate language impairment in children using cochlear implants

Deafness and Specific Learning Disorder: towards a possible comorbidity

BACKGROUND AND AIM

Most children and adolescents with deafness receive one or two cochlear implants (CIs). Despite the CI expanding the potential for auditory rehabilitation in deaf children, the improvements in language and literacy skills of some of these children do not align with the expected outcomes. As the main research question, we wondered if the reading and writing deficits reported in some deaf children with CIs may be characterized as a domain-specific learning disorder, rather than only a consequence of deafness. Thus, we analyzed the academic discrepancies, in both reading and writing, between two groups of deaf children with early CI.

METHOD

Three prelingually deaf children with CI and with unexplained disproportionate learning disorders (Deaf+LD group) were compared to control deaf children with similar clinical history, age at CI implantation and auditory experience (Deaf group). The Deaf+LD group was also matched on chronological age to three hearing children with Specific Learning Disorder (SLD group).

RESULTS

The results showed that the three cases of the Deaf+LD group demonstrated severe reading and writing deficits, with performances significantly below the age level, similarly to children of the SLD group. By contrast, the three children of the Deaf group demonstrated normal reading and writing abilities.

CONCLUSIONS

We suggested considering the possibility of comorbidity between deafness and SLD. This hypothesis was supported by the specific features of the language profile that justify such an association; in fact, deaf children with presumed SLD have profiles much more similar to hearing children with SLD than to other deaf children.

Children With Developmental Language Disorder Have Lower Quality of Life Than Children With Typical Development and Children With Cochlear Implants

PURPOSE

The purpose of this study was to examine quality of life (QOL) and its relation to language skills in children with developmental language disorder (DLD). This was examined by comparing QOL to a control group of children with typical development (TD), as well as children with cochlear implants (CIs), who potentially struggle with language for language, although for a different reason than children with DLD.

METHOD

Two groups of children, a group with TD (n = 29) and a group of children with CIs (n = 29), were matched to the DLD group (n = 29) on chronological age, gender, nonverbal IQ, and parental educational level through a propensity matching procedure. A third group consisting of children with CIs was also matched to the DLD group but additionally matched on language abilities. QOL scores were compared across groups, and the association between language skills and QOL was examined in the DLD group.

RESULT

The DLD group was reported by parents to have statistically significantly poorer QOL scores than peers with TD or CIs. When controlling for language skills, either statistically or through an additional CI group matched on language abilities, there were no statistically significant differences in QOL scores across groups. In the DLD group, language skills explained 16% of the variation in QOL.

CONCLUSION

DLD is associated with the children's overall QOL, and the degree of reduced QOL relates to the severity of the language impairment.

Identifying Developmental Language Disorder in Deaf Children with Cochlear Implants: A Case Study of Three Children

(1) Background: While spoken language learning delays are assumed for deaf and hard of hearing (DHH) children after cochlear implant (CI), many catch up with their hearing peers. Some DHH children with CIs, however, show persistent delays in language, despite protective factors being in place. This suggests a developmental language disorder (DLD). However, at present there is little consensus on how to diagnose DLD in DHH children. (2) Methods: Given the lack of consensus in this area, a set of case studies provides an appropriate first step. The goal of this paper is to show the plausibility of a DLD diagnosis, following careful analysis of protective and risk factors. A retrospective case study review was conducted for three children. Their long-term language outcomes up to four years after CI were considered in the context of access to sound, speech sound discrimination, social skills and non-verbal cognition. (3) Results: It was possible to posit DLD in one child who had experienced good access to sound, alongside good speech discrimination abilities and social development, and normal non-verbal cognition, but who presented with severe language learning difficulties. (4) Conclusions: Finding markers for DLD in DHH children is important for diagnosis and intervention. The implications for clinical practice are discussed.

Long-Term Device Satisfaction and Safety after Cochlear Implantation in Children

(1) Objectives: For full benefit in children implanted with a cochlear implant (CI), wearing the device all waking hours is necessary. This study focuses on the relationship between daily use and audiological outcomes, with the hypothesis that frequent daily device use coincides with high device satisfaction resulting in better functional gain (FG). Confounding factors such as implantation age, device experience and type of device were considered. (2) Results: Thirty-eight CI children (65 ears) were investigated. In total, 76.92% of the children were using their device for >12 h per day (h/d), 18.46% for 9−12 h/d, the remaining for 6−9 h/d and one subject reported 3 h/d. The revision rate up to the 90-month follow-up (F/U) was 4.6%. The mean FG was 59.00 ± 7.67 dB. The Audio Processor Satisfaction Questionnaire (APSQ) separated for single unit (SU) versus behind the ear (BTE) devices showed significantly better results for the latter in terms of wearing comfort (WC) (p = 0.00062). A correlation between device use and FG was found with a device experience of <2 years (n = 29; r2 = 0.398), whereas no correlation was seen with ≥2 years of device experience (n = 36; r2 = 0.0038). (3) Conclusion: This study found significant relationships between daily device use and FG, wearing comfort and long-term safety (90 months).

Does Phonological Complexity Provide a Good Index of Language Disorder in Children With Cochlear Implants?

Purpose Phonological complexity is known to be a good index of developmental language disorder (DLD) in normal-hearing children, who have major difficulties on some complex structures. Some deaf children with cochlear implants (CIs) present a profile that evokes DLD, with persistent linguistic difficulties despite good audiological and environmental conditions. However, teasing apart what is related to auditory deficit or to language disorder remains complex. Method We compared the performance of three groups of school-age children, 33 children with CI, 22 with DLD, and 24 with typical development, on a nonword repetition (NWR) task based on phonological complexity. Children with CI were studied regarding their linguistic profile, categorized in four subgroups ranging from excellent to very poor performance. Influence of syllable length and phonological structures on the results of all the children were explored. Results The NWR task correctly distinguished children with DLD from typically developing children, and also children with CI with the poorest linguistic performance from other children with CI. However, most complex phonological structures did not reliably identify children with CI displaying a profile similar to that of children with DLD because these structures were difficult for all of the children with CI. The simplest phonological structures were better at detecting persistent language difficulties in children with CI, as they were challenging only for the children with the poorest language outcomes. Conclusions The most complex phonological structures are not good indices of language disorder in children with CI. Phonological complexity represents a gradient of difficulty that affects normal-hearing and deaf children differently.

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.

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.

Narrative competence in Italian children with cochlear implants: a comparison with children matched by chronological or hearing age

The present study aimed to analyse the narrative competence of a group of Italian children with a bilateral cochlear implant (CI) implanted before 30 months of age. Participants were ten children with CI (aged from 42 to 83 months) and two control groups of typically hearing children one-to-one paired by sex, non-verbal reasoning, and chronological or hearing age. A story generation task, specifically developed to assess narrative skills in children (i.e., the Narrative Competence Task) was used to evaluate both macrostructural and microstructural features of the children's narratives. Results showed that children with CI presented only one significant difference in the macrostructural aspects of narratives compared to typically hearing children matched by hearing age, specifically in the higher number of events told. In addition, concerning microstructural features, the only statistically significant difference was a lower lexical variety in the narratives produced by children with CI than in those produced by typically hearing children matched by chronological age. Both macrostructural and microstructural indices appeared to be related to the hearing age of children with CI. Early CI appeared to play a crucial role in the acquisition of a complex area of language development, as narrative competence.

Does size of the cochlear nerve affect postoperative auditory performance in pediatric cochlear implant patients with normal cochlear nerves?

Introduction

Cochlear implantation is an effective treatment method for severe to profound hearing loss. Many factors that may influence cochlear implantation success have been explained in previous studies. Apart from those, minor differences in size of normal cochlear nerves may affect postoperative performance.

Objective

To investigate whether the minor differences in cochlear nerve size in normal cochlear nerves affect postoperative cochlear implant performance.

Methods

30 pediatric prelingually deaf patients who were treated with cochlear implantation were included in this study. From the reconstructed parasagittal magnetic resonance images, the diameter and cross-sectional area of the cochlear nerve on the ipsilateral and contralateral side were measured. Auditory evaluations were performed 1, 3, 6 and 12 months following the first fitting. All the analysis was performed by using EARS®, evaluation of auditory responses to speech tool. Correlation between cochlear nerve diameter, cross-sectional area and postoperative auditory perception was analyzed to determine whether variation in cochlear nerve size contributes to postoperative auditory performance.

Results

The mean diameter of the cochlear nerve on the ipsilateral side was 718.4 μm (504.5 − 904.3 μm) and mean cross sectional area was 0.015 cm² (0.012 − 0.018 cm²). On the contralateral side the mean cochlear nerve diameter was 714.4 μm (502.6 − 951.4 μm) and mean cross sectional area was 0.014 cm² (0.011 − 0.019 cm²). The correlation between the diameter and cross-sectional area of the ipsilateral and contralateral cochlear nerve revealed no significance. Mean score at first month monosyllable-trochee-polysyllable test, MTP1, was 0.17 (0.08 − 0.33), at 6th month with 6 words test, 6th month MTP6 was 0.72 (0.39 − 1.0), at 6th month with 12 words, 6th month MTP 12 was 0.46 (0.17 − 0.75) and at 12th month with 12 words, 12th month MTP12 was 0.73 (0.25 − 1.0). There was no correlation between the monosyllable-trochee-polysyllable test, values at any time with the diameter of the ipsilateral cochlear nerve. However, the first month MTP, 6th month MTP6 and 12th month MTP12 correlated with the cross-sectional area of the ipsilateral cochlear nerve.

Conclusion

Measuring the cross sectional area of the normal- appearing cochlear nerve may give important prognostic knowledge on cochlear implant outcomes. In patients with a larger cross sectional area the auditory performance was better and faster. Although normal appearing, slight differences on cross sectional area of the cochlear nerve may affect performance. Measuring the size of the cochlear nerve on parasagittal magnetic resonance images may provide beneficial information on the postoperative rehabilitation process.

Performance of Children With Hearing Loss on an Audiovisual Version of a Nonword Repetition Task

Purpose The aims of this study were to (a) determine if a high-quality adaptation of an audiovisual nonword repetition task can be completed by children with wide-ranging hearing abilities and to (b) examine whether performance on that task is sensitive to child demographics, hearing status, language, working memory, and executive function abilities. Method An audiovisual version of a nonword repetition task was adapted and administered to 100 school-aged children grouped by hearing status: 35 with normal hearing, 22 with mild bilateral hearing loss, 17 with unilateral hearing loss, and 26 cochlear implant users. Participants also completed measures of vocabulary, working memory, and executive function. A generalized linear mixed-effects model was used to analyze performance on the nonword repetition task. Results All children were able to complete the nonword repetition task. Children with unilateral hearing loss and children with cochlear implants repeated nonwords with less accuracy than normal-hearing peers. After adjusting for the influence of vocabulary and working memory, main effects were found for syllable length and hearing status, but no interaction effect was observed. Conclusions The audiovisual nonword repetition task captured individual differences in the performance of children with wide-ranging hearing abilities. The task could act as a useful tool to aid in identifying children with unilateral or mild bilateral hearing loss who have language impairments beyond those imposed by the hearing loss.

Impact of reading and writing skills on academic achievement among school-aged hearing-impaired children

OBJECTIVES

Reading and writing skills are important for hearing-impaired children since these skills help them to develop their language skills, but the prevalence of reading/writing difficulties and its effects on language development aspects among them are unclear. In this study, we identified language development features and demographic factors of Japanese hearing-impaired children diagnosed as having reading/writing difficulties.

METHODS

We analyzed data from a total of 546 sever-to-profound pre-school and elementary school hearing-impaired children for this study. Children with reading/writing difficulties (Group A) were defined as children obtaining low scores (-1.5 SD compared to others in the same grade) in the Screening Test of Reading and Writing for Japanese Primary School Children (STRAW), and we compared other language development features (communication ability, vocabulary, syntax and academic achievement) and demographic factors to those of hearing-impaired children with normal reading and writing skills (Group B). We assessed language development domains as outcomes using the Assessment of Language Development for Japanese Children (ALADJIN) package, and analyzed the results stratified by age groups (5-6, 7-8, 9-10, and 11-12 years) using multiple regression analyses.

RESULTS

The prevalence of reading/writing difficulties was 20.1% among the participants. Almost all point estimates in each language development domain showed better odds ratios (OR) except Criterion Referenced Test -II (CRT-II) mathematics in 11- to 12-year-olds in fully-adjusted models. Among 9- to 10-year-olds, the ORs (95% confidence interval) for fair academic achievement measured by CRT-II were 2.60 (1.09-6.20) for Japanese and 3.02 (1.29-7.11) for mathematics in Group B, even after adjusting for possible confounding factors.

CONCLUSIONS

Reading and writing are important for language development of hearing-impaired children, especially for academic achievement during the middle phase of elementary school. Screening for reading/writing difficulties is important for appropriate intervention and to prevent language and academic delays among hearing-impaired children.

Why is it so hard to reach agreement on terminology? The case of developmental language disorder (DLD)

A recent project entitled CATALISE used the Delphi method to reach a consensus on terminology for unexplained language problems in children. 'Developmental language disorder' (DLD) was the term agreed by a panel of 57 experts. Here I reflect on points of difficulty that arose when attempting to reach a consensus, using qualitative information from comments made by panel members to illustrate the kinds of argument used. One issue of debate was the use of labels, in particular the term 'disorder', which was seen as having both pros and cons. The potential for labels to stigmatize or create low expectations was a particular concern. However, labels could also ensure language problems were not trivialized and could help avoid stigma by providing an explanation for behaviours that might otherwise meet with disapproval. Further debate surrounded issues of how best to identify cases of disorder. Although it was agreed there should be a focus on cases with a poor prognosis, it was recognized that our knowledge of factors related to prognosis was still incomplete. Furthermore, there was a tension between use of standardized tests, which allow for a relatively objective and reliable assessment of language, and more qualitative observations, which can capture functional aspects of communication that are not always picked up on formal assessment. Debate also surrounded the issue of the relationship between DLD and other conditions. Some favoured drawing a distinction between DLD and language disorders associated with other conditions, and others regarded such distinctions as unnecessary. We concluded that it was misleading to assume co-occurring conditions were causes of language disorder, but it was helpful to distinguish DLD from cases of language disorder associated with 'differentiating conditions' that had a known or likely biomedical origin, including brain injury, sensorineural hearing loss, genetic syndromes, intellectual disability and autism spectrum disorder. Furthermore, DLD could co-occur with milder neurodevelopmental disorders that did not have a clear biomedical aetiology. Normal-range non-verbal IQ has traditionally been incorporated in the diagnosis of DLD, but this was rejected as unsupported by evidence. DLD is a category that has utility in identifying children who would benefit from speech-language therapy services, but it should not be thought of as a well-defined condition. DLD has a multifactorial aetiology, is heterogeneous in terms of language features and overlaps with other neurodevelopmental disorders. Our notions of DLD are likely to be refined by further research into aetiology, associated characteristics and intervention effectiveness.

Breaking the sound barrier: exploring parents' decision-making process of cochlear implants for their children

OBJECTIVE

To understand the dynamic experiences of parents undergoing the decision-making process regarding cochlear implants for their child(ren).

METHODS

Thirty-three parents of d/Deaf children participated in semi-structured interviews. Interviews were digitally recorded, transcribed, and coded using iterative and thematic coding.

RESULTS

The results from this study reveal four salient topics related to parents' decision-making process regarding cochlear implantation: 1) factors parents considered when making the decision to get the cochlear implant for their child (e.g., desire to acculturate child into one community), 2) the extent to which parents' communities influence their decision-making (e.g., norms), 3) information sources parents seek and value when decision-making (e.g., parents value other parent's experiences the most compared to medical or online sources), and 4) personal experiences with stigma affecting their decision to not get the cochlear implant for their child.

CONCLUSION

This study provides insights into values and perspectives that can be utilized to improve informed decision-making, when making risky medical decisions with long-term implications.

PRACTICAL IMPLICATIONS

With thorough information provisions, delineation of addressing parents' concerns and encompassing all aspects of the decision (i.e., medical, social and cultural), health professional teams could reduce the uncertainty and anxiety for parents in this decision-making process for cochlear implantation.

Altered Brain Functional Activity in Infants with Congenital Bilateral Severe Sensorineural Hearing Loss: A Resting-State Functional MRI Study under Sedation

Early hearing deprivation could affect the development of auditory, language, and vision ability. Insufficient or no stimulation of the auditory cortex during the sensitive periods of plasticity could affect the function of hearing, language, and vision development. Twenty-three infants with congenital severe sensorineural hearing loss (CSSHL) and 17 age and sex matched normal hearing subjects were recruited. The amplitude of low frequency fluctuations (ALFF) and regional homogeneity (ReHo) of the auditory, language, and vision related brain areas were compared between deaf infants and normal subjects. Compared with normal hearing subjects, decreased ALFF and ReHo were observed in auditory and language-related cortex. Increased ALFF and ReHo were observed in vision related cortex, which suggest that hearing and language function were impaired and vision function was enhanced due to the loss of hearing. ALFF of left Brodmann area 45 (BA45) was negatively correlated with deaf duration in infants with CSSHL. ALFF of right BA39 was positively correlated with deaf duration in infants with CSSHL. In conclusion, ALFF and ReHo can reflect the abnormal brain function in language, auditory, and visual information processing in infants with CSSHL. This demonstrates that the development of auditory, language, and vision processing function has been affected by congenital severe sensorineural hearing loss before 4 years of age.

Linguistic profiles of children with CI as compared with children with hearing or specific language impairment

BACKGROUND

The spoken language difficulties of children with moderate or severe to profound hearing loss are mainly related to limited auditory speech perception. However, degraded or filtered auditory input as evidenced in children with cochlear implants (CIs) may result in less efficient or slower language processing as well. To provide insight into the underlying nature of the spoken language difficulties in children with CIs, linguistic profiles of children with CIs are compared with those of hard-of-hearing (HoH) children with conventional hearing aids and children with specific language impairment (SLI).

AIMS

To examine differences in linguistic abilities and profiles of children with CIs as compared with HoH children and children with SLI, and whether the spoken language difficulties of children with CIs mainly lie in limited auditory perception or in language processing problems.

METHODS & PROCEDURE

Differences in linguistic abilities and differential linguistic profiles of 47 children with CI, 66 HoH children with moderate to severe hearing loss, and 127 children with SLI are compared, divided into two age cohorts. Standardized Dutch tests were administered. Factor analyses and cluster analyses were conducted to find homogeneous linguistic profiles of the children.

OUTCOMES & RESULTS

The children with CIs were outperformed by their HoH peers and peers with SLI on most linguistic abilities. Concerning the linguistic profiles, the largest group of children with CIs and HoH children shared similar profiles. The profiles observed for most of the children with SLI were different from those of their peers with hearing loss in both age cohorts.

CONCLUSIONS & IMPLICATIONS

Results suggest that the underlying nature of spoken language problems in most children with CIs manifests in limited auditory perception instead of language processing difficulties. However, there appears to be a subgroup of children with CIs whose linguistic profiles resemble those of children with SLI.

Pediatric Cochlear Implantation: Why Do Children Receive Implants Late?

OBJECTIVES

Early cochlear implantation has been widely promoted for children who derive inadequate benefit from conventional acoustic amplification. Universal newborn hearing screening has led to earlier identification and intervention, including cochlear implantation in much of the world. The purpose of this study was to examine age and time to cochlear implantation and to understand the factors that affected late cochlear implantation in children who received cochlear implants.

DESIGN

In this population-based study, data were examined for all children who underwent cochlear implant surgery in one region of Canada from 2002 to 2013. Clinical characteristics were collected prospectively as part of a larger project examining outcomes from newborn hearing screening. For this study, audiologic details including age and severity of hearing loss at diagnosis, age at cochlear implant candidacy, and age at cochlear implantation were documented. Additional detailed medical chart information was extracted to identify the factors associated with late implantation for children who received cochlear implants more than 12 months after confirmation of hearing loss.

RESULTS

The median age of diagnosis of permanent hearing loss for 187 children was 12.6 (interquartile range: 5.5, 21.7) months, and the age of cochlear implantation over the 12-year period was highly variable with a median age of 36.2 (interquartile range: 21.4, 71.3) months. A total of 118 (63.1%) received their first implant more than 12 months after confirmation of hearing loss. Detailed analysis of clinical profiles for these 118 children revealed that late implantation could be accounted for primarily by progressive hearing loss (52.5%), complex medical conditions (16.9%), family indecision (9.3%), geographical location (5.9%), and other miscellaneous known (6.8%) and unknown factors (8.5%).

CONCLUSIONS

This study confirms that despite the trend toward earlier implantation, a substantial number of children can be expected to receive their first cochlear implant well beyond their first birthday because they do not meet audiologic criteria of severe to profound hearing loss for cochlear implantation at the time of identification of permanent hearing loss. This study underscores the importance of carefully monitoring all children with permanent hearing loss to ensure that optimal intervention including cochlear implantation occurs in a timely manner.

CATALISE: A Multinational and Multidisciplinary Delphi Consensus Study. Identifying Language Impairments in Children

Delayed or impaired language development is a common developmental concern, yet there is little agreement about the criteria used to identify and classify language impairments in children. Children's language difficulties are at the interface between education, medicine and the allied professions, who may all adopt different approaches to conceptualising them. Our goal in this study was to use an online Delphi technique to see whether it was possible to achieve consensus among professionals on appropriate criteria for identifying children who might benefit from specialist services. We recruited a panel of 59 experts representing ten disciplines (including education, psychology, speech-language therapy/pathology, paediatrics and child psychiatry) from English-speaking countries (Australia, Canada, Ireland, New Zealand, United Kingdom and USA). The starting point for round 1 was a set of 46 statements based on articles and commentaries in a special issue of a journal focusing on this topic. Panel members rated each statement for both relevance and validity on a seven-point scale, and added free text comments. These responses were synthesised by the first two authors, who then removed, combined or modified items with a view to improving consensus. The resulting set of statements was returned to the panel for a second evaluation (round 2). Consensus (percentage reporting 'agree' or 'strongly agree') was at least 80 percent for 24 of 27 round 2 statements, though many respondents qualified their response with written comments. These were again synthesised by the first two authors. The resulting consensus statement is reported here, with additional summary of relevant evidence, and a concluding commentary on residual disagreements and gaps in the evidence base.

CATALISE: A Multinational and Multidisciplinary Delphi Consensus Study. Identifying Language Impairments in Children

Delayed or impaired language development is a common developmental concern, yet there is little agreement about the criteria used to identify and classify language impairments in children. Children's language difficulties are at the interface between education, medicine and the allied professions, who may all adopt different approaches to conceptualising them. Our goal in this study was to use an online Delphi technique to see whether it was possible to achieve consensus among professionals on appropriate criteria for identifying children who might benefit from specialist services. We recruited a panel of 59 experts representing ten disciplines (including education, psychology, speech-language therapy/pathology, paediatrics and child psychiatry) from English-speaking countries (Australia, Canada, Ireland, New Zealand, United Kingdom and USA). The starting point for round 1 was a set of 46 statements based on articles and commentaries in a special issue of a journal focusing on this topic. Panel members rated each statement for both relevance and validity on a seven-point scale, and added free text comments. These responses were synthesised by the first two authors, who then removed, combined or modified items with a view to improving consensus. The resulting set of statements was returned to the panel for a second evaluation (round 2). Consensus (percentage reporting 'agree' or 'strongly agree') was at least 80 percent for 24 of 27 round 2 statements, though many respondents qualified their response with written comments. These were again synthesised by the first two authors. The resulting consensus statement is reported here, with additional summary of relevant evidence, and a concluding commentary on residual disagreements and gaps in the evidence base.

Predictors of pediatric cochlear implantation outcomes in South Africa

OBJECTIVE

To identify and describe predictors of pediatric cochlear implantation outcomes in a South African population.

METHODS

A retrospective study of 301 pediatric cochlear implant (CI) recipients from five CI programs was conducted and cross-sectional outcome data were added at the time of data collection. Twenty potential prognostic factors were identified from the retrospective dataset, including demographical, CI, risk and family factors. Multiple regression analyses were performed to identify predictor variables that influence outcomes in terms of auditory performance (CAP scores), speech production (SIR scores), communication mode and educational placement.

RESULTS

Although implanted children within this sample did not have equal opportunity to access a second implant, bilateral implantation was strongly predictive of better auditory performance and speech production scores, an oral mode of communication and mainstream education. NICU admittance/prematurity were associated with poorer auditory performance and speech production scores, together with a higher probability for non-oral communication and non-mainstream education. The presence of one or more additional developmental condition was predictive of poorer outcomes in terms of speech production and educational placement, while a delay between diagnosis and implantation of more than one year was also related to non-mainstream education. Ethnicities other than Caucasian were predictive of poorer auditory performance scores and a lower probability for mainstream education.

CONCLUSION

An extensive range of prognostic indicators were identified for pediatric CI outcomes in South Africa. These predictive factors of better and poorer outcomes should guide pediatric CI services to promote optimal outcomes and assist professionals in providing evidence-based informational counseling.

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.

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

PURPOSE

The purpose of the present investigation is to differentiate children using cochlear implants (CIs) who did or did not achieve age-appropriate language scores by midelementary grades and to identify risk factors for persistent language delay following early cochlear implantation.

MATERIALS AND METHOD

Children receiving unilateral CIs at young ages (12-38 months) were tested longitudinally and classified with normal language emergence (n = 19), late language emergence (n = 22), or persistent language delay (n = 19) on the basis of their test scores at 4.5 and 10.5 years of age. Relative effects of demographic, audiological, linguistic, and academic characteristics on language emergence were determined.

RESULTS

Age at CI was associated with normal language emergence but did not differentiate late emergence from persistent delay. Children with persistent delay were more likely to use left-ear implants and older speech processor technology. They experienced higher aided thresholds and lower speech perception scores. Persistent delay was foreshadowed by low morphosyntactic and phonological diversity in preschool. Logistic regression analysis predicted normal language emergence with 84% accuracy and persistent language delay with 74% accuracy.

CONCLUSION

CI characteristics had a strong effect on persistent versus resolving language delay, suggesting that right-ear (or bilateral) devices, technology upgrades, and improved audibility may positively influence long-term language outcomes.

Deaf parents of cochlear-implanted children: beliefs on bimodal bilingualism

This study investigated 17 Deaf (1) families in North America with cochlear-implanted children about their attitudes, beliefs, and practices on bimodal bilingualism (defined as using both a visual/manual language and an aural/oral language) in American Sign Language (ASL) and English. A survey and follow-up interviews with 8 families were conducted. The majority of the Deaf families exhibited positive beliefs toward bimodal bilingualism, where they set high expectations for their children to become equally fluent in both languages. However, their perspectives about the purpose for each language differed; they viewed English as a "survival language" and ASL as a "cultural language" but supported the use of both languages at home as part of their children's lives.

Ten questions about terminology for children with unexplained language problems

BACKGROUND

In domains other than language, there is fairly consistent diagnostic terminology to refer to children's developmental difficulties. For instance, the terms 'dyslexia', 'attention deficit hyperactivity disorder' and 'autistic spectrum disorder' are used for difficulties with reading, attention or social cognition, respectively. There is no agreed label, however, for children with unexplained language problems.

AIMS

To consider whether we need labels for unexplained language problems in children, and if so, what terminology is appropriate.

MAIN CONTRIBUTION

There are both advantages and disadvantages to labels, but they are important to ensure children receive services, and to increase our knowledge of the nature and causes of such problems. A survey of labels in current use found 132 different terms, 33 of which had 600 or more returns on Google Scholar between 1994 and 2013. Many of these labels were too general to be useful. Of the remainder, the term 'specific language impairment' was the most commonly used.

CONCLUSIONS

The current mayhem in diagnostic labels is unsustainable; it causes confusion and impedes research progress and access to appropriate services. We need to achieve consensus on diagnostic criteria and terminology. The DSM-5 term 'language disorder' is problematic because it identifies too wide a range of conditions on an internet search. One solution is to retain specific language impairment, with the understanding that 'specific' means idiopathic (i.e., of unknown origin) rather than implying there are no other problems beyond language. Other options are the terms 'primary language impairment', 'developmental language disorder' or 'language learning impairment'.

The strengths and weaknesses in verbal short-term memory and visual working memory in children with hearing impairment and additional language learning difficulties

OBJECTIVES

To compare verbal short-term memory and visual working memory abilities of six children with congenital hearing-impairment identified as having significant language learning difficulties with normative data from typically hearing children using standardized memory assessments.

METHODS

Six children with hearing loss aged 8-15 years were assessed on measures of verbal short-term memory (Non-word and word recall) and visual working memory annually over a two year period. All children had cognitive abilities within normal limits and used spoken language as the primary mode of communication. The language assessment scores at the beginning of the study revealed that all six participants exhibited delays of two years or more on standardized assessments of receptive and expressive vocabulary and spoken language.

RESULTS

The children with hearing-impairment scores were significantly higher on the non-word recall task than the "real" word recall task. They also exhibited significantly higher scores on visual working memory than those of the age-matched sample from the standardized memory assessment.

CONCLUSIONS

Each of the six participants in this study displayed the same pattern of strengths and weaknesses in verbal short-term memory and visual working memory despite their very different chronological ages. The children's poor ability to recall single syllable words in relation to non-words is a clinical indicator of their difficulties in verbal short-term memory. However, the children with hearing-impairment do not display generalized processing difficulties and indeed demonstrate strengths in visual working memory. The poor ability to recall words, in combination with difficulties with early word learning may be indicators of children with hearing-impairment who will struggle to develop spoken language equal to that of their normally hearing peers. This early identification has the potential to allow for target specific intervention that may remediate their difficulties.

Practitioners' perspectives on the functioning of school-age children with cochlear implants

OBJECTIVE

The availability of cochlear implants has increased the number of children with profound deafness educated in classrooms alongside peers with normal hearing. The purpose of this research was to better understand the functioning of these children from the perspective of their service providers.

METHODS

Semi-structured focus group interviews were conducted with 28 practitioners to elicit their perceptions of children's abilities in oral communication, academic, and social functioning. Data were coded inductively and examined through content analysis.

RESULTS

The central theme was that cochlear implantation has improved school functioning for children both in hearing and related spoken language abilities and beyond hearing in academic and social development. While these benefits were a consistent theme, a wide range of performance was identified across all areas of functioning. In particular, areas of concern included full participation in classroom activities and social interaction with peers.

CONCLUSIONS

The findings provide insights into functioning for children with cochlear implants from the perspective of those who interact with them in everyday settings. These findings underscore the challenges for children in achieving full participation despite improvements in communication skills. Practitioners identified areas where intervention is required to facilitate the inclusion of children in school programs.

Computer-assisted training of phoneme-grapheme correspondence for children who are deaf and hard of hearing: effects on phonological processing skills

OBJECTIVE

Examine deaf and hard of hearing (DHH) children's phonological processing skills in relation to a reference group of children with normal hearing (NH) at two baselines pre intervention. Study the effects of computer-assisted phoneme-grapheme correspondence training in the children. Specifically analyze possible effects on DHH children's phonological processing skills.

METHODS

The study included 48 children who participated in a computer-assisted intervention study, which focuses on phoneme-grapheme correspondence. Children were 5, 6, and 7 years of age. There were 32 DHH children using cochlear implants (CI) or hearing aids (HA), or both in combination, and 16 children with NH. The study had a quasi-experimental design with three test occasions separated in time by four weeks; baseline 1 and 2 pre intervention, and 3 post intervention. Children performed tasks measuring lexical access, phonological processing, and letter knowledge. All children were asked to practice ten minutes per day at home supported by their parents.

RESULTS

NH children outperformed DHH children on the majority of tasks. All children improved their accuracy in phoneme-grapheme correspondence and output phonology as a function of the computer-assisted intervention. For the whole group of children, and specifically for children with CI, a lower initial phonological composite score was associated with a larger phonological change between baseline 2 and post intervention. Finally, 18 DHH children, whereof 11 children with CI, showed specific intervention effects on their phonological processing skills, and strong effect sizes for their improved accuracy of phoneme-grapheme correspondence.

CONCLUSION

For some DHH children phonological processing skills are boosted relatively more by phoneme-grapheme correspondence training. This reflects the reciprocal relationship between phonological change and exposure to and manipulations of letters.

Enhancement technology and outcomes: what professionals and researchers can learn from those skeptical about cochlear implants

This text presents an overview of the bioethical debate on pediatric cochlear implants and pays particular attention to the analysis of the Deaf critique of implantation. It dismisses the idea that Deaf concerns are primarily about the upholding of Deaf culture and sign language. Instead it is argued that Deaf skepticism about child rehabilitation after cochlear surgery is well founded. Many Deaf people have lived experiences as subjects undergoing rehabilitation. It is not the cochlear technology in itself they view as problematic, but rather the subsequent rehabilitation process. Because they themselves have experienced what they describe as harmful effects which relate above all to the idea of normalization, they have articulated worries for the new generations of deaf children in need of rehabilitation following cochlear implant surgery. These insights have attracted little attention, but could represent relevant ethical questions of which both practitioners and researchers in the field of implantation might be aware.

Emergent literacy in kindergartners with cochlear implants

OBJECTIVE

A key ingredient to academic success is being able to read. Deaf individuals have historically failed to develop literacy skills comparable with those of their normal-hearing (NH) peers, but early identification and cochlear implants (CIs) have improved prospects such that these children can learn to read at the levels of their peers. The goal of this study was to examine early, or emergent, literacy in these children.

METHOD

Twenty-seven deaf children with CIs, who had just completed kindergarten were tested on emergent literacy, and on cognitive and linguistic skills that support emergent literacy, specifically ones involving phonological awareness, executive functioning, and oral language. Seventeen kindergartners with NH and eight with hearing loss, but who used hearing aids served as controls. Outcomes were compared for these three groups of children, regression analyses were performed to see whether predictor variables for emergent literacy differed for children with NH and those with CIs, and factors related to the early treatment of hearing loss and prosthesis configuration were examined for children with CIs.

RESULTS

The performance of children with CIs was roughly 1 SD or more below the mean performance of children with NH on all tasks, except for syllable counting, reading fluency, and rapid serial naming. Oral language skills explained more variance in emergent literacy for children with CIs than for children with NH. Age of first implant explained moderate amounts of variance for several measures. Having one or two CIs had no effect, but children who had some amount of bimodal experience outperformed children who had none on several measures.

CONCLUSIONS

Even deaf children who have benefitted from early identification, intervention, and implantation are still at risk for problems with emergent literacy that could affect their academic success. This finding means that intensive language support needs to continue through at least the early elementary grades. Also, a period of bimodal stimulation during the preschool years can help boost emergent literacy skills to some extent.

What factors are associated with good performance in children with cochlear implants? From the outcome of various language development tests, research on sensory and communicative disorders project in Japan: nagasaki experience

Objectives

We conducted multi-directional language development tests as a part of the Research on Sensory and Communicative Disorders (RSVD) in Japan. This report discusses findings as well as factors that led to better results in children with severe-profound hearing loss.

Methods

We evaluated multiple language development tests in 33 Japanese children with cochlear implants (32 patients) and hearing aid (1 patient), including 1) Test for question and answer interaction development, 2) Word fluency test, 3) Japanese version of the Peabody picture vocabulary test-revised, 4) The standardized comprehension test of abstract words, 5) The screening test of reading and writing for Japanese primary school children, 6) The syntactic processing test of aphasia, 7) Criterion-referenced testing (CRT) for Japanese language and mathematics, 8) Pervasive development disorders ASJ rating scales, and 9) Raven's colored progressive matrices. Furthermore, we investigated the factors believed to account for the better performances in these tests. The first group, group A, consisted of 14 children with higher scores in all tests than the national average for children with hearing difficulty. The second group, group B, included 19 children that scored below the national average in any of the tests.

Results

Overall, the results show that 76.2% of the scores obtained by the children in these tests exceeded the national average scores of children with hearing difficulty. The children who finished above average on all tests had undergone a longer period of regular habilitation in our rehabilitation center, had their implants earlier in life, were exposed to more auditory verbal/oral communication in their education at affiliated institutions, and were more likely to have been integrated in a regular kindergarten before moving on to elementary school.

Conclusion

In this study, we suggest that taking the above four factors into consideration will have an affect on the language development of children with severe-profound hearing loss.

Cochlear implant in the second year of life: lexical and grammatical outcomes

PURPOSE

The authors studied the effect of the cochlear implant (CI) on language comprehension and production in deaf children who had received a CI in the 2nd year of life.

METHOD

The authors evaluated lexical and morphosyntactic skills in comprehension and production in 17 Italian children who are deaf (M = 54 months of age) with a CI and in 2 control groups of children with normal hearing (NH; 1 matched for chronological age and the other whose chronological age corresponded to the duration of CI activation). The authors also compared children with unilateral CI to children with bilateral CI.

RESULTS

Children with CI appeared to keep pace with NH children matched for time since CI activation in terms of language acquisition, and they were similar to same-age NH children in lexical production. However, children with CI showed difficulties in lexical comprehension when a task required phonological discrimination as well as in grammar comprehension and production. Children with bilateral CI showed better comprehension than did children with unilateral CI; the 2 groups were similar for production.

CONCLUSIONS

Activation of CI in the 2nd year of life may provide children who are deaf with a good opportunity to develop language skills, although some limitations in phonological and morphological skills are still present 3 years after auditory reafferentation.

Assessment Package for Language Development in Japanese Hearing-Impaired Children (ALADJIN) as a Test Battery for the Development of Practical Communication

Objectives:

The measurement of language development in hearing-impaired children is an important step in assessing the appropriateness of an intervention. We proposed a set of language tests (the Assessment Package for Language Development in Japanese Hearing-Impaired Children [ALADJIN]) to evaluate the development of practical communication skills. This package consisted of communication skills (TQAID), comprehensive (PVT-R and SCTAW) and productive vocabulary (WFT), comprehensive and productive syntax (STA), and the STRAW.

Methods:

A total of 638 children with greater than 70-dB hearing impairment were subjected to this set of language tests. Additional tests, including the PARS, the RCPM, and parental questionnaires, were administered to assess the backgrounds of the children.

Results:

A trimodal distribution was observed among hearing-impaired children by the histogram-based analysis of each test.

Conclusions:

The ALADJIN is a useful Japanese-language evaluation kit for hearing-impaired children.

Syntactic Development in Japanese Hearing-Impaired Children

Objectives:

This study examined syntactic development of auditory comprehension of sentences in Japanese-speaking school-age children with and without hearing impairment.

Methods:

In total, 592 preschool and school-age children (421 normal-hearing and 171 hearing-impaired) were included in this cross-sectional observation study conducted using the Syntactic Processing Test for Aphasia for Japanese language users. Linear regression analysis was used to determine the estimated age at which each syntactic structure was acquired.

Results:

Acquisition of syntactic structures was observed in hearing-impaired and normal-hearing children. Basic word order sentences of agent-object-verb and the goal benefactive construction were acquired at preschool age (earlier group), whereas reverse word order sentences of object-agent-verb, source benefactive construction, passive voice, and relative clauses were acquired at school age (later group). The results showed that many hearing-impaired children may not acquire Japanese grammatical structures until the age of 12 years.

Conclusions:

Adequate screening for language development for school-age hearing-impaired children is required for an effective intervention.

Factors predicting functional outcomes of cochlear implants in children

This article reports the relationships between a large number of child- and family-related factors and children's functional outcomes, according to parental report, in the domains of spoken language communication, social skills and participation, academic achievement, and independence and identity, through a series of stepwise regression analyses. Parents of 247 children who had received cochlear implants in three eastern states of Australia completed a survey on their expectations and experiences of their children's outcomes with cochlear implants. A number of the independent variables were found to be associated, either positively or negatively, with children's outcomes. Implications for cochlear implant professionals, early intervention programmes, and educational authorities are discussed.

Processes that influence communicative impairments in deaf children using cochlear implants

OBJECTIVES

We previously presented evidence for the existence of a "disproportionate language impairment" (DLI) in a small sample of children using a cochlear implant (CI) who had a good surgical outcome and who were otherwise unimpaired, including typical nonverbal intelligence quotient. Herein, we studied a larger sample of children with DLI who were CI users and, as before, paired them with closely matched, "Control" children who were CI users but had more typical language skills. The primary aim was to assess the communication skills of siblings of each group of CI users to seek evidence for the inheritance of language and more general communicative impairments in the DLI group. We also investigated laterality as a possible coindicator of impairment among the CI users.

DESIGN

Prelingually deaf children using a single CI and presenting with severe unexplained language problems (DLI-CI, N = 25) were compared with a group of children using a CI who did not present with such difficulties (Control-CI, N = 25). The groups were matched on age, gender, etiology, age at implantation, implant manufacturer, duration of deafness, and CI experience. Members of both groups completed a series of nonverbal and verbal tests used to identify specific language impairment in normal-hearing (NH) children, and tests of cerebral laterality. Parents completed the Children's Communication Checklist (CCC-2) for each of their children (i.e., the CI users and all their siblings; sibling results were grouped as DLI-Sibling and Control-Sibling) and a questionnaire regarding family history of hearing, speech, language, and literacy problems of the children's first-degree relatives.

RESULTS

Significant differences of performance on all language tests were found between the DLI-CI and the Control-CI groups. No difference was found between the groups on performance intelligence quotient or auditory memory. CCC-2 results indicated lower General Communication Composite and higher Social Interaction Deviance Composite scores in the DLI-CI than in the Control-CI group. All children in the DLI-CI group produced abnormal overall profiles compared with less than half the children in the Control-CI group. CCC-2 results for the siblings showed a significant association between sibling group and communication; 35% in the DLI-Sibling group produced abnormal profiles compared with 8% in the Control-Sibling group. Co-occurring deafness and language problems in a small number of siblings and other family members did not account fully for these communication difficulties, but there was a higher prevalence of these difficulties in the families of both groups than is reported in NH families. Laterality tasks did not show significant differences between the groups of CI users, although there were trends for children in the DLI-CI group to have less dominant hand preference and eye-hand dominance than those in the Control-CI group and in NH children.

CONCLUSIONS

Language tests, including the CCC-2, could identify communication difficulties in children using CIs, leading to prompt identification, informed intervention strategies, and managed expectations. Evidence from their siblings suggests that these difficulties may not all be determined by their deafness or device characteristics but through the same heritable and environmental factors that influence language development in all children.

Cortical thickness analysis and optimized voxel-based morphometry in children and adolescents with prelingually profound sensorineural hearing loss

Crossmodal neuroplastic changes following auditory deprivation in individuals with profound sensorineural hearing loss (SNHL) have been well documented in previous literature. However, previous studies have shown very little evidence of structural brain changes in individuals with prelingually profound SNHL and no studies have reported significant differences of gray matter (GM) in deaf subjects. Therefore, it is essential to employ a more specific and sensitive technique to detect subtle structural brain differences in deaf individuals. The objective of our study was to investigate neuroanatomical differences in children and adolescents with profound SNHL by cortical thickness analysis and optimized voxel-based morphometry (VBM). T1-weighted volumetric images of 16 children and adolescents with prelingually profound SNHL and 16 hearing controls were analyzed. The ANCOVA analysis revealed a statistically significant decreased average cortical thickness of the whole brain. As to vertex-based analysis, cortical thickness of the deaf subjects showed significant thinning in the left precentral gyrus, right postcentral gyrus, the left superior occipital gyrus and the left fusiform gyrus compared with the hearing subjects. VBM revealed statistically significant focal reduction of white matter (WM) volume in the left middle frontal gyrus and the right inferior occipital gyrus in deaf subjects without statistically significant differences in GM volume between the two groups. These findings demonstrated that structural changes happened not only in the WM but also in the GM of the subjects with prelingually profound SNHL, which have never been reported before in any previous literature. Our results also implicated the potential neuroplastic changes associated with crossmodal reorganization in the brain after auditory deprivation in the early deafness.

Communication, psychosocial, and educational outcomes of children with cochlear implants and challenges remaining for professionals and parents

This paper provides an overview and a synthesis of the findings of a large, multifaceted study investigating outcomes from paediatric cochlear implantation. The study included children implanted at several Australian implant clinics and attending a variety of early intervention and educational settings across a range of locations in eastern Australia. It investigated three major aspects of childhood cochlear implantation: (1) parental expectations of their children's implantation, (2) families' decision-making processes, and (3) the communication, social, and educational outcomes of cochlear implantation for deaf children. It employed a mixed-methods approach in which quantitative survey data were gathered from 247 parents and 151 teachers, and qualitative data from semistructured interviews with 27 parents, 15 teachers, and 11 children and adolescents with cochlear implants. The summarised findings highlight several areas where challenges remain for implant clinics, parents, and educators if children with cochlear implants are to reach their full potential personally, educationally, and socially.

Neurodevelopmental disorders in children with severe to profound sensorineural hearing loss: a clinical study

AIM

The effects of sensorineural hearing loss (SNHL) are often complicated by additional disabilities, but the epidemiology of associated disorders is not clearly defined. The aim of this study was to evaluate the frequency and type of additional neurodevelopmental disabilities in a sample of children with SNHL and to investigate the relation between these additional disabilities and the aetiology of deafness.

METHOD

One hundred children with severe/profound SNHL (60 males, 40 females; mean age 5 y 7 mo, SD 3 y 6 mo, range 8 mo-16 y) were investigated using a diagnostic protocol including neurodevelopmental, genetic, neurometabolic, and brain magnetic resonance imaging (MRI) assessment.

RESULTS

Forty-eight per cent of the sample exhibited one or more additional disabilities, with cognitive, behavioural-emotional, and motor disorders being the most frequent. The risk of additional disabilities varied according to the type of aetiology. Thirty-seven out of 80 individuals with available MRIs showed signal abnormalities, in particular brain malformations (46%) and white matter abnormalities (54%). Frequency and type of disability were associated with aetiology (p=0.015) and MRI data (p<0.001).

INTERPRETATION

A multidimensional evaluation, including aetiological, neurodevelopmental, and MRI investigation, is needed for planning therapeutic intervention, such as cochlear implantation in children with severe to profound hearing impairment. The aetiology of deafness is a relevant risk indicator for the presence of an associated disorder.

Choosing for the child with cochlear implants: a note of precaution

Recent contributions to discussions on paediatric cochlear implantation in Norway indicate two mutually exclusive doctrines prescribing the best course of post-operative support for a child with cochlear implants; bilingually with sign language and spoken language simultaneously or primarily monolingually with speech only. This conflict constitutes an ethical problem for parents responsible for choosing between one of the two alternatives. This article puts forth the precautionary principle as a possible solution to this problem. Although scientific uncertainty exists in the case of both doctrines, there exists a scenario of possible irreversible harm to some of the children habilitated monolingually. An application of the precautionary principle may hence suggest that it is rational to agree on the bilingual approach, at least for the time-being.

Coming to a decision about cochlear implantation: parents making choices for their deaf children

This study combined quantitative and qualitative methods in a sequential approach to investigate the experiences of parents making decisions about cochlear implants for their deaf children. Quantitative findings from a survey instrument completed by 247 parents were extended and elaborated by qualitative findings from in-depth interviews with 27 of the survey respondents. Although parents used a variety of information sources when considering an implant, cochlear implant centers and doctors comprised their major source of information. Most parents found the decision-making process difficult and stressful, but a proportion reported finding the decision easy, believing that there was no other option for their child, and were keen for implantation to proceed as soon as possible. Implications for professionals working with families are discussed.

Language achievement in children who received cochlear implants between 1 and 2 years of age: group trends and individual patterns

This study examined receptive and expressive vocabulary and grammar achievement of French-speaking children (n = 27) who received a cochlear implant (CI) between the age of 1 and 2. Standardized measures of language achievement were administered and the language levels attained by children with CIs were compared with that of the normative sample of same-age hearing peers for each measure. As a group, children exhibited language levels within normal limits in all standardized language measures. Examination of individual patterns revealed four different language profiles ranging from normal language levels in all domains to general language delay. Half the participants displayed language levels on par with similar-age peers at the word level; less than half the children obtained average performance at the sentence level. In three of these profiles, comprehension of sentences was impaired. Moreover, the age at implantation was not associated with language achievement. Findings suggest that receiving a CI between the age of 1 and 2 years does not ensure that language abilities will be within normal limits after up to 6 years of experience with the implant.

Use of auditory learning to manage listening problems in children

This paper reviews recent studies that have used adaptive auditory training to address communication problems experienced by some children in their everyday life. It considers the auditory contribution to developmental listening and language problems and the underlying principles of auditory learning that may drive further refinement of auditory learning applications. Following strong claims that language and listening skills in children could be improved by auditory learning, researchers have debated what aspect of training contributed to the improvement and even whether the claimed improvements reflect primarily a retest effect on the skill measures. Key to understanding this research have been more circumscribed studies of the transfer of learning and the use of multiple control groups to examine auditory and non-auditory contributions to the learning. Significant auditory learning can occur during relatively brief periods of training. As children mature, their ability to train improves, but the relation between the duration of training, amount of learning and benefit remains unclear. Individual differences in initial performance and amount of subsequent learning advocate tailoring training to individual learners. The mechanisms of learning remain obscure, especially in children, but it appears that the development of cognitive skills is of at least equal importance to the refinement of sensory processing. Promotion of retention and transfer of learning are major goals for further research.