Cochlear Implants or Hearing Aids: Speech Perception, Language, and Executive Function Outcomes.

OBJECTIVES: We aimed to determine whether children with severe hearing loss (HL) who use hearing aids (HAs) may experience added value in the perception of speech, language development, and executive function (EF) compared to children who are hard of hearing (HH) or children who are deaf and who use cochlear implants (CIs) and would benefit from CIs over HAs. The results contribute to the ongoing debate concerning CI criteria. We addressed the following research question to achieve this aim: Do children who are HH or deaf with CIs perform better than children with severe HL with HAs with respect to auditory speech perception, and receptive vocabulary and/or EF? DESIGN: We compared two groups of children with severe HL, profound HL or deafness, with CIs or HAs, matched for gender, test age (range, 8 to 15 years), socioeconomic status, and nonverbal intelligence quotient. Forty-three children had CIs (pure-tone average at 2000 and 4000 Hz >85 dB HL), and 27 children had HAs (mean pure-tone average: 69 dB HL). We measured speech perception at the conversational level (65 dB SPL) and the soft speech perception level (45 dB SPL). We established receptive vocabulary using the Peabody Picture Vocabulary Test-III-NL. We tested EF using the Delis Kaplan Executive Function System battery and the Dutch Rey Auditory Verbal Learning Test. We employed the Mann-Whitney U test to compare data between the CI and HA groups. We used Chi-square goodness of fit tests to contrast the CI and HA group distributions with the norm data of children who are typically developing (TD). We harnessed Kendall's Tau-b to investigate relationships between the study variables. RESULTS: Both groups of children, with CIs and Has, obtained ceiling scores for perception of speech on a conversational level. However, the HA group exhibited significantly lower perception on a soft speech level scores (68 %) than the CI group (87%). No difference was present between the receptive vocabulary distributions of the CI and HA groups. The median receptive vocabulary standard scores for both groups were well within the normal range (CI group: 93; HA group: 96). In addition, we did not find any difference in EF between the CI and HA groups. For planning and verbal memory, the distributions of observed scores for children with CIs were different from the expected distributions of children who are TD. In both groups, a large proportion of children obtained below-average scores for planning (CI: 44%; HA: 33%) and for long-term verbal memory (CI: 44%; HA: 35%). In the HA group, perception at a soft speech level was associated with receptive vocabulary and planning. In the CI group, we did not find any associations. CONCLUSIONS: Both groups of children with severe and profound HL with HAs exhibit less favorable auditory perception on the soft speech level, but not at a conversational level, compared to children who are HH or deaf with CIs. Both groups, children with CIs and HAs, only exhibit more problems in planning and verbal memory than the norm groups of children who are TD. The results indicate that to obtain age-appropriate levels of receptive vocabulary and EF, the perception at the soft speech level is a necessary but not sufficient prerequisite.

Capability of Children with Hearing Devices: A Mixed Methods Study.

We investigated 34 deaf and hard-of-hearing children with hearing devices aged 8-12 years and 30 typical hearing peers. We used the capability approach to assess well-being in both groups through interviews. Capability is "the real freedom people have to do and to be what they have reason to value." Speech perception, phonology, and receptive vocabulary data of the deaf and hard-of-hearing children, that were used retrospectively, showed a large variability. The analysis of the relation between clinical quantitative outcome measures and qualitative capability interview outcomes suggests that at this age, differences in clinical performance do not appear to translate into considerable differences in capability, including capability did offer insight into the factors that appeared to ensure this equivalence of capability. We argue that capability outcomes should be used to determine the focus of (auditory) rehabilitation and support, in line with the United Nations Convention on the Rights of the Child.

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.

Wellbeing as Capability: Findings in Hearing-Impaired Adolescents and Young Adults With a Hearing Aid or Cochlear Implant.

In the Western world, for deaf and hard-of-hearing children, hearing aids or cochlear implants are available to provide access to sound, with the overall goal of increasing their wellbeing. If and how this goal is achieved becomes increasingly multifarious when these children reach adolescence and young adulthood and start to participate in society in other ways. An approach to wellbeing that includes personal differences and the relative advantages and disadvantages that people have, is the capability approach, as developed by Nobel Prize laureate Amartya Sen. Capability is the set of real opportunities people have to do and be things they have reason to value. We interviewed 59 young people, aged 13 through 25, with cochlear implants (37) or hearing aids (22) to capture their capability. We found that their hearing devices enabled them to actively participate in a predominantly hearing society, with few differences between cochlear implant and hearing aid recipients. They did, however, report challenges associated with prejudices and expectations, and with feeling poorly understood, all of which appeared to impact their capability. Through the lens of capability, alleged differences between hearing aid and cochlear implant recipients began to fade. We discuss the implications for initiatives focused on the long-term support young recipients of hearing devices to meet their specific requirements over time.

Capability of deaf children with a cochlear implant.

INTRODUCTION: The main idea underlying this paper is that impairments such as deafness are particularly relevant to the extent that they lead to deprivation of capability. Likewise, the impact of healthcare services such as cochlear implants and subsequent rehabilitation can best be inferred from the extent that they protect or restore capability of those affected. METHODS: To explore children's post-implant capabilities, we tested two newly developed digital, adaptive child self-report and parent-report questionnaires in 19 deaf children (aged 8-12 years) and their parents during rehabilitation, as well as in 23 age peers with normal hearing. RESULTS: Despite the impressive speech-language results that were recorded with cochlear implants, the post-implant capabilities of the deaf children we evaluated differed from those of their hearing peers, with the cochlear implant group appearing particularly disadvantaged in areas such as accessing information, communication, social participation, and participation in school. CONCLUSION: Deaf children with cochlear implants who are performing well on linguistic and auditory tests can still experience serious limitations in desired functioning. Our findings suggest that a capability approach may reveal aspects of what is being achieved through rehabilitation that might otherwise remain unnoticed, and that could help to further improve the well-being of our patients.IMPLICATIONS FOR REHABILITATIONOverall, children with cochlear implants appeared disadvantaged in certain capability areas, like accessing information, communication, social participation, and participation in school.It may be worthwhile to also ascertain capabilities in these children, representing a domain not covered by clinical measures, tapping directly into areas that are valuable to the patient.

Classroom performance and language development of CI students placed in mainstream elementary school.

OBJECTIVE: Investigation of the relation between classroom performance and language development of cochlear implant (CI) students in mainstream education. Structural analyses of assessment of mainstream performance (AMP) and Screening Instrument For Targeting Educational Risk (SIFTER) instruments. STUDY DESIGN: Cross-sectional instrument and language development analyses. SETTING: Tertiary university medical center. PATIENTS: Twenty-six CI children in elementary school with congenital or prelingual deafness were included. At the time of this study, mean period of multichannel CI use was 5.3 years, and children's ages ranged from 6.5 to 12.8 years. MAIN OUTCOME MEASURE: Assessment of mainstream performance and SIFTER instruments measured classroom performance and language development were measured by means of Reynell and Schlichting tests. RESULTS: Assessment of mainstream performance and SIFTER domains showed good reliability (Cronbach alpha >0.6), but factor analyses only showed the expected instrument structure in the AMP. In both questionnaires and within all domains, individual variability is detected. Spearman's correlation analyses showed the probable explanation of individual questionnaire variability by language test results (p value mostly <0.01). The AMP and SIFTER instruments showed a predictive capacity for language development, based upon general linear model univariate and linear regression analyses. CONCLUSION: Individual classroom performance, measured by AMP and SIFTER questionnaires, of CI children in mainstream education varies. Correlation analyses showed strong significant relation between questionnaire results (classroom performance) and both expressive and receptive language test results (Schlichting and Reynell tests). Structural questionnaire analyses of the AMP and SIFTER demonstrated good reliability. The predictive value of the AMP can monitor the actual linguistic functioning of the child.

Classroom performance of children with cochlear implants in mainstream education.

OBJECTIVES: We compared classroom performance of children with a cochlear implant (CI) with that of their normal-hearing peers in mainstream education. METHODS: Thirty-two CI children in mainstream education, congenitally or prelingually deaf, participated in this study, as did 37 hearing classmates. Their teachers filled out 2 questionnaires: the Assessment of Mainstream Performance (AMP) and the Screening Instrument for Targeting Educational Risk (SIFTER). A high Fletcher index and open-set speech perception scores were obtained. RESULTS: The children with CIs scored above average on the AMP and sufficiently well in all but one area (communication) of the SIFTER questionnaire. Class rankings did not differ significantly between the CI students and their normal-hearing peers. Overall, the normal-hearing group outperformed the CI group. The classroom performance of CI children correlated negatively with duration of deafness and age at implantation. All longitudinal audiological data of the CI children showed improvement in open-set speech recognition. CONCLUSIONS: Although the results are encouraging, the CI group scored significantly less well than their normal-hearing peers on most questionnaire domains of both the AMP and the SIFTER. The most important variables for the outcome in this study were age at implantation and duration of deafness.

Auditory and verbal memory predictors of spoken language skills in children with cochlear implants.

BACKGROUND: Large variability in individual spoken language outcomes remains a persistent finding in the group of children with cochlear implants (CIs), particularly in their grammatical development. AIMS: In the present study, we examined the extent of delay in lexical and morphosyntactic spoken language levels of children with CIs as compared to those of a normative sample of age-matched children with normal hearing. Furthermore, the predictive value of auditory and verbal memory factors in the spoken language performance of implanted children was analyzed. METHODS & PROCEDURES: Thirty-nine profoundly deaf children with CIs were assessed using a test battery including measures of lexical, grammatical, auditory and verbal memory tests. Furthermore, child-related demographic characteristics were taken into account. OUTCOMES & RESULTS: The majority of the children with CIs did not reach age-equivalent lexical and morphosyntactic language skills. Multiple linear regression analyses revealed that lexical spoken language performance in children with CIs was best predicted by age at testing, phoneme perception, and auditory word closure. The morphosyntactic language outcomes of the CI group were best predicted by lexicon, auditory word closure, and auditory memory for words. CONCLUSIONS: Qualitatively good speech perception skills appear to be crucial for lexical and grammatical development in children with CIs. Furthermore, strongly developed vocabulary skills and verbal memory abilities predict morphosyntactic language skills.

Benefits of simultaneous bilateral cochlear implantation on verbal reasoning skills in prelingually deaf children.

BACKGROUND: Impaired auditory speech perception abilities in deaf children with hearing aids compromised their verbal intelligence enormously. The availability of unilateral cochlear implantation (CI) auditory speech perception and spoken vocabulary enabled them to reach near ageappropriate levels. This holds especially for children in spoken language environments. However, speech perception in complex listening situations and the acquisition of complex verbal skills remains difficult. Bilateral CI was expected to enhance the acquisition of verbal intelligence by improved understanding of speech in noise. METHODS: This study examined the effect of bilateral CI on verbal intelligence of 49 deaf children (3;5-8;0 years). Relations between speech perception in noise, auditory short-term memory and verbal intelligence were analysed with multiple linear regressions. In addition, the interaction of educational setting, mainstream or special, on these relations was analysed. RESULTS: Children with bilateral CI obtained higher scores on verbal intelligence. Significant associations were present between speech perception in noise, auditory short-term memory and verbal intelligence. CONCLUSION: Children with simultaneous bilateral CIs showed better speech perception in noise than children with unilateral CIs, which mediated by the auditory short-term memory capacity, enhanced the ability to acquire more complex verbal skills for BICI children in mainstream education.

Lexical access in children with hearing loss or specific language impairment, using the cross-modal picture-word interference paradigm.

In this study we compared lexical access to spoken words in 25 deaf children with cochlear implants (CIs), 13 hard-of-hearing (HoH) children and 20 children with specific language impairment (SLI). Twenty-one age-matched typically developing children served as controls. The children with CIs and the HoH children in the present study had good speech perception abilities. We used a cross-modal picture-word interference paradigm to examine lexical access. Results showed that children with SLI revealed overall slower reaction times and produced more errors than the children with CIs, the HoH children, and the control children. Reaction times of children with CIs and the HoH children did not differ from those of the control children. Thus, problems with spoken language processing, as is the case in children with SLI, seem to affect lexical access more than limitations in auditory perception, as is the fundamental problem in children with hearing loss. We recommend that improvement of lexical access in children with SLI deserves specific attention in therapy and education.

Long-term outcomes on spatial hearing, speech recognition and receptive vocabulary after sequential bilateral cochlear implantation in children.

Sequential bilateral cochlear implantation in profoundly deaf children often leads to primary advantages in spatial hearing and speech recognition. It is not yet known how these children develop in the long-term and if these primary advantages will also lead to secondary advantages, e.g. in better language skills. The aim of the present longitudinal cohort study was to assess the long-term effects of sequential bilateral cochlear implantation in children on spatial hearing, speech recognition in quiet and in noise and receptive vocabulary. Twenty-four children with bilateral cochlear implants (BiCIs) were tested 5-6 years after sequential bilateral cochlear implantation. These children received their second implant between 2.4 and 8.5 years of age. Speech and language data were also gathered in a matched reference group of 26 children with a unilateral cochlear implant (UCI). Spatial hearing was assessed with a minimum audible angle (MAA) task with different stimulus types to gain global insight into the effective use of interaural level difference (ILD) and interaural timing difference (ITD) cues. In the long-term, children still showed improvements in spatial acuity. Spatial acuity was highest for ILD cues compared to ITD cues. For speech recognition in quiet and noise, and receptive vocabulary, children with BiCIs had significant higher scores than children with a UCI. Results also indicate that attending a mainstream school has a significant positive effect on speech recognition and receptive vocabulary compared to attending a school for the deaf. Despite of a period of unilateral deafness, children with BiCIs, participating in mainstream education obtained age-appropriate language scores.

Cochlear implantation in late-implanted prelingually deafened adults: changes in quality of life.

BACKGROUND: With expanding inclusion criteria for cochlear implantation, the number of prelingually deafened persons who are implanted as adults increases. Compared with postlingually deafened adults, this group shows limited improvement in speech recognition. In this study, the changes in health-related quality of life in late-implanted prelingually deafened adults are evaluated and related to speech recognition. METHODS: Quality of life was measured before implantation and 1 year after implantation in a group of 28 prelingually deafened adults, who had residual hearing and who used primarily oral communication. Patients completed 3 questionnaires (Nijmegen Cochlear Implant Questionnaire, Glasgow Benefit Inventory, and Health Utility Index 3). Postoperative scores were compared with preoperative scores. Additionally, phoneme recognition scores were obtained preimplantation and 1 year postimplantation. RESULTS: Quality of life improved after implantation: scores on the Nijmegen Cochlear Implant Questionnaire improved significantly in all subdomains (basic speech perception, advanced speech perception, speech production, self-esteem, activity, and social interaction), the total Glasgow Benefit Inventory score improved significantly, and the Health Utility Index 3 showed a significant improvement in the utility score and in the subdomains "hearing" and "emotion." Additionally, a significant improvement in speech recognition scores was found. No significant correlations were found between gain in quality of life and speech perception scores. CONCLUSION: The results suggest that quality of life and speech recognition in prelingually deafened adults significantly improved as a result of cochlear implantation. Lack of correlation between quality of life and speech recognition suggests that in evaluating performance after implantation in prelingually deafened adults, measures of both speech recognition and quality of life should be used.