The Association of Race With Decreased Access to Pediatric Hearing Healthcare in the United States.

Successful intervention to support a child with congenital hearing loss requires early identification and consistent access to frequent professional services. In the early 2000s, the United States implemented an initiative, Early Hearing Detection and Intervention (EHDI), to provide timely identification and treatment of congenital hearing loss. This national program aims to screen hearing by 1 month of age, diagnose hearing loss by 3 months of age, and provide intervention to infants with hearing loss by 6 months of age. To date, the United States is successfully implementing hearing screening by 1 month of age but continually struggling to diagnose and treat congenital hearing loss promptly for many infants. This article begins by exploring the current state of American children and families, focusing on social determinants of health, specifically race and poverty. The objective is to understand how race affects social determinants of health, and ultimately hearing healthcare access for children. A narrative literature review spanning public health, sociology, and hearing research was completed to inform this work. The current body of literature supports the conclusion that race and racism, separate from poverty, lead to decreased access to pediatric hearing healthcare. Interventions targeting these issues are necessary to improve timely access to hearing loss diagnosis and treatment for American children.

Common Sounds Audiograms: Quantitative Analyses and Recommendations.

A counseling tool routinely used by pediatric audiologists and early intervention-specialists is the often-named "common sounds audiogram" (CSA). Typically, a child's hearing detection thresholds are plotted on the CSA to indicate that child's audibility of speech and environmental sounds. Importantly, the CSA may be the first item that parents see when their child's hearing loss is explained. Thus, the accuracy of the CSA and its associated counseling information are integral to the parents' understanding of what their child can hear and to the parents' role in the child's future hearing care and interventions. Currently available CSAs were collected from professional societies, early intervention providers, device manufacturers, etc., and analyzed ( n = 36). Analysis included quantification of sound elements, presence of counseling information, attribution of acoustic measurements, and errors. The analyses show that currently-available CSAs are wildly inconsistent as a group, not scientifically justified, and omit important information for counseling and interpretation. Variations found among currently available CSAs can lead to very different parental interpretations of the impact of a child's hearing loss on his/her access to sounds, especially spoken language. Such variations, presumably, could also lead to different recommendations regarding intervention and hearing devices. Recommendations are outlined for the development of a new, standard CSA.

Effects of Segmental and Suprasegmental Speech Perception on Reading in Pediatric Cochlear Implant Recipients.

PURPOSE: The aim of this study was to determine whether suprasegmental speech perception contributes unique variance in predictions of reading decoding and comprehension for prelingually deaf children using two devices, at least one of which is a cochlear implant (CI). METHOD: A total of 104, 5- to 9-year-old CI recipients completed tests of segmental perception (e.g., word recognition in quiet and noise, recognition of vowels and consonants in quiet), suprasegmental perception (e.g., talker and stress discrimination, nonword stress repetition, and emotion identification), and nonverbal intelligence. Two years later, participants completed standardized tests of reading decoding and comprehension. Using regression analyses, the unique contribution of suprasegmental perception to reading skills was determined after controlling for demographic characteristics and segmental perception performance. RESULTS: Standardized reading scores of the CI recipients increased with nonverbal intelligence for both decoding and comprehension. Female gender was associated with higher comprehension scores. After controlling for gender and nonverbal intelligence, segmental perception accounted for approximately 4% and 2% of the variance in decoding and comprehension, respectively. After controlling for nonverbal intelligence, gender, and segmental perception, suprasegmental perception accounted for an extra 4% and 7% unique variance in reading decoding and reading comprehension, respectively. CONCLUSIONS: Suprasegmental perception operates independently from segmental perception to facilitate good reading outcomes for these children with CIs. Clinicians and educators should be mindful that early perceptual skills may have long-term benefits for literacy. Research on how to optimize suprasegmental perception, perhaps through hearing-device programming and/or training strategies, is needed.

Considerations in pediatric device candidacy: An emphasis on spoken language.

As cochlear implant (CI) candidacy expands to consider children with more residual hearing, the use of a CI and a hearing aid (HA) at the non-implanted ear (bimodal devices) is increasing. This case study examines the contributions of acoustic and electric input to speech perception performance for a pediatric bimodal device user (S1) who is a borderline bilateral cochlear implant candidate. S1 completed a battery of perceptual tests in CI-only, HA-only and bimodal conditions. Since CIs and HAs differ in their ability to transmit cues related to segmental and suprasegmental perception, both types of perception were tested. Performance in all three device conditions were generally similar across tests, showing no clear device-condition benefit. Further, S1's spoken language performance was compared to those of a large group of children with prelingual severe-profound hearing loss who used two devices from a young age, at least one of which was a CI. S1's speech perception and language scores were average or above-average compared to these other pediatric CI recipients. Both segmental and suprasegmental speech perception, and spoken language skills should be examined to determine the broad-scale performance level of bimodal recipients, especially when deciding whether to move from bimodal devices to bilateral CIs.

Spectral Modulation Detection Performance and Speech Perception in Pediatric Cochlear Implant Recipients.

PURPOSE: The aims of this study were, for pediatric cochlear implant (CI) recipients, (a) to determine the effect of age on their spectral modulation detection (SMD) ability and compare their age effect to that of their typically hearing (TH) peers; (b) to identify demographic, cognitive, and audiological factors associated with SMD ability; and (c) to determine the unique contribution of SMD ability to segmental and suprasegmental speech perception performance. METHOD: A total of 104 pediatric CI recipients and 38 TH peers (ages 6-11 years) completed a test of SMD. CI recipients completed tests of segmental (e.g., word recognition in noise and vowels and consonants in quiet) and suprasegmental (e.g., talker discrimination, stress discrimination, and emotion identification) perception, nonverbal intelligence, and working memory. Regressions analyses were used to examine the effects of group and age on percent-correct SMD scores. For the CI group, the effects of demographic, audiological, and cognitive variables on SMD performance and the effects of SMD on speech perception were examined. RESULTS: The TH group performed significantly better than the CI group on SMD. Both groups showed better performance with increasing age. Significant predictors of SMD performance for the CI group were age and nonverbal intelligence. SMD performance predicted significant variance in segmental and suprasegmental perception. The variance predicted by SMD performance was nearly double for suprasegmental than for segmental perception. CONCLUSIONS: Children in the CI group, on average, scored lower than their TH peers. The slopes of improvement in SMD with age did not differ between the groups. The significant effect of nonverbal intelligence on SMD performance in CI recipients indicates that difficulties inherent in the task affect outcomes. SMD ability predicted speech perception scores, with a more prominent role in suprasegmental than in segmental speech perception. SMD ability may provide a useful nonlinguistic tool for predicting speech perception benefit, with cautious interpretation based on age and cognitive function.

Self-reported hearing quality of life measures in pediatric cochlear implant recipients with bilateral input.

Objective: Self-reported hearing quality of life (QoL) for pediatric cochlear implant (CI) recipients was examined, asking whether 1) children with CIs have similar QoL as those with less severe hearing loss (HL); 2) children with different bilateral CI (BCI) device configurations report different QoL; and 3) do audiological, demographic and spoken language factors affect hearing QoL?Design: One hundred four children (ages 7-11 years) using bimodal devices or BCIs participated. The Hearing Environments and Reflection of Quality of Life (HEAR-QL) questionnaire, receptive language and speech perception tests were administered. HEAR-QL scores of CI recipients were compared to scores of age-mates with normal hearing and mild to profound HL.Results: HEAR-QL scores for CI participants were similar to those of children with less severe HL and did not differ with device configuration. Emotion identification and word recognition in noise correlated significantly with HEAR-QL scores.Discussion: CI recipients reported that HL hinders social participation. Better understanding of speech in noise and emotional content was associated with fewer hearing-related difficulties on the HEAR-QL.Conclusions: Noisy situations encountered in educational settings should be addressed for children with HL. The link between perception of emotion and hearing-related QoL for CI recipients should be further examined.

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

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

The Effect of Cochlear Implant Interval on Spoken Language Skills of Pediatric Bilateral Cochlear Implant Users.

OBJECTIVE: To examine the effects of cochlear implant (CI) interval (time between CI surgeries) on receptive vocabulary and receptive language skills for children with bilateral CIs. STUDY DESIGN: A prospective cross-sectional study design. SETTING: Participants were recruited from, and tested at, oral schools for the deaf and pediatric audiology clinics across the United States. PATIENTS: Eighty-eight children, 4 to 9 years of age, with bilateral CIs and known hearing histories. Twenty-three participants received CIs simultaneously and 65 received CIs sequentially. Of those implanted sequentially, 86% wore a hearing aid (HA) on the non-implanted ear during the CI interval. INTERVENTION: Bilateral cochlear implantation. MAIN OUTCOME MEASURES: Receptive vocabulary was measured via the Peabody Picture Vocabulary Test (PPVT). Receptive language skills were measured via the Clinical Evaluation of Language Fundamentals (CELF). RESULTS: Multiple linear regression models indicate better receptive vocabulary and receptive language skills are associated with earlier ages at first CI (CI 1), but not with shorter CI intervals. CONCLUSIONS: Early cochlear implantation (i.e., age at CI 1) is critical for better receptive vocabulary and receptive language skills. Shorter CI intervals are not associated with better receptive vocabulary and receptive language skills for these 88 children, who nearly all used bimodal hearing during the interval. Use of a HA at the non-implanted ear, before receipt of a second CI (CI 2), may mitigate the effects of early bilateral auditory deprivation.

Preimplant Hearing Aid Fittings and Aided Audibility for Pediatric Cochlear Implant Recipients.

BACKGROUND: Audibility of speech for children with hearing loss (HL) depends on the degree of HL and the fitting of the hearing aids (HAs) themselves. Many studies on cochlear implant (CI) users have demonstrated that preimplant hearing is associated with postimplant outcomes, but there have been very few reports on the fitting of HAs before surgery. PURPOSE: The aims of this study were to characterize HA fittings and aided audibility of speech for pediatric HA users with severe to profound HL and to examine the relation between preimplant aided audibility and postimplant speech perception. RESEARCH DESIGN: A descriptive/observational and correlational study. Audiologic records of pediatric CI participants involved in a larger study examining the effects of early acoustic hearing were analyzed retrospectively; when available, these records included HA verification and speech recognition performance. STUDY SAMPLE: The CI participants were enrolled in audiology centers and oral schools for the deaf across the United States. DATA COLLECTION AND ANALYSIS: To determine whether deviations from prescribed DSL target were significantly greater than zero, 95% confidence intervals of the mean deviation were calculated for each frequency (250, 500, 1000, 2000, and 4000 Hz). Correlational analyses were used to examine the relationship between preimplant aided Speech Intelligibility Indices (SIIs) and postimplant speech perception in noise. Correlational analyses were also used to explore the relationship between preimplant aided SIIs and demographic data. T-tests were used to compare preimplant-aided SIIs of HAs of listeners who later became users of either sequential CIs, simultaneous CIs, or bimodal devices. RESULTS: Preimplant fittings of HAs were generally very close to prescriptive targets, except at 4000 Hz for those HAs with active frequency-lowering processing, and preimplant SIIs, albeit low, were correlated with postimplant speech recognition performance in noise. These results suggest that aided audibility should be maximized throughout the HA trial for later speech recognition purposes. CONCLUSIONS: It is recommended that HA fittings be optimized to support speech audibility even when considering implantation. In addition to the age at which HA use begins, the aided audibility itself is important in determining CI candidacy and decisions regarding bimodal HA use.

Effects of Early Auditory Deprivation on Working Memory and Reasoning Abilities in Verbal and Visuospatial Domains for Pediatric Cochlear Implant Recipients.

OBJECTIVES: The overall goal of this study was to compare verbal and visuospatial working memory in children with normal hearing (NH) and with cochlear implants (CI). The main questions addressed by this study were (1) Does auditory deprivation result in global or domain-specific deficits in working memory in children with CIs compared with their NH age mates? (2) Does the potential for verbal recoding affect performance on measures of reasoning ability in children with CIs relative to their NH age mates? and (3) Is performance on verbal and visuospatial working memory tasks related to spoken receptive language level achieved by children with CIs? DESIGN: A total of 54 children ranging in age from 5 to 9 years participated; 25 children with CIs and 29 children with NH. Participants were tested on both simple and complex measures of verbal and visuospatial working memory. Vocabulary was assessed with the Peabody Picture Vocabulary Test (PPVT) and reasoning abilities with two subtests of the WISC-IV (Wechsler Intelligence Scale for Children, 4th edition): Picture Concepts (verbally mediated) and Matrix Reasoning (visuospatial task). Groups were compared on all measures using analysis of variance after controlling for age and maternal education. RESULTS: Children with CIs scored significantly lower than children with NH on measures of working memory, after accounting for age and maternal education. Differences between the groups were more apparent for verbal working memory compared with visuospatial working memory. For reasoning and vocabulary, the CI group scored significantly lower than the NH group for PPVT and WISC Picture Concepts but similar to NH age mates on WISC Matrix Reasoning. CONCLUSIONS: Results from this study suggest that children with CIs have deficits in working memory related to storing and processing verbal information in working memory. These deficits extend to receptive vocabulary and verbal reasoning and remain even after controlling for the higher maternal education level of the NH group. Their ability to store and process visuospatial information in working memory and complete reasoning tasks that minimize verbal labeling of stimuli more closely approaches performance of NH age mates.

Segmental and Suprasegmental Perception in Children Using Hearing Aids.

BACKGROUND: Suprasegmental perception (perception of stress, intonation, "how something is said" and "who says it") and segmental speech perception (perception of individual phonemes or perception of "what is said") are perceptual abilities that provide the foundation for the development of spoken language and effective communication. While there are numerous studies examining segmental perception in children with hearing aids (HAs), there are far fewer studies examining suprasegmental perception, especially for children with greater degrees of residual hearing. Examining the relation between acoustic hearing thresholds, and both segmental and suprasegmental perception for children with HAs, may ultimately enable better device recommendations (bilateral HAs, bimodal devices [one CI and one HA in opposite ears], bilateral CIs) for a particular degree of residual hearing. Examining both types of speech perception is important because segmental and suprasegmental cues are affected differentially by the type of hearing device(s) used (i.e., cochlear implant [CI] and/or HA). Additionally, suprathreshold measures, such as frequency resolution ability, may partially predict benefit from amplification and may assist audiologists in making hearing device recommendations. PURPOSE: The purpose of this study is to explore the relationship between audibility (via hearing thresholds and speech intelligibility indices), and segmental and suprasegmental speech perception for children with HAs. A secondary goal is to explore the relationships among frequency resolution ability (via spectral modulation detection [SMD] measures), segmental and suprasegmental speech perception, and receptive language in these same children. RESEARCH DESIGN: A prospective cross-sectional design. STUDY SAMPLE: Twenty-three children, ages 4 yr 11 mo to 11 yr 11 mo, participated in the study. Participants were recruited from pediatric clinic populations, oral schools for the deaf, and mainstream schools. DATA COLLECTION AND ANALYSIS: Audiological history and hearing device information were collected from participants and their families. Segmental and suprasegmental speech perception, SMD, and receptive vocabulary skills were assessed. Correlations were calculated to examine the significance (p < 0.05) of relations between audibility and outcome measures. RESULTS: Measures of audibility and segmental speech perception are not significantly correlated, while low-frequency pure-tone average (unaided) is significantly correlated with suprasegmental speech perception. SMD is significantly correlated with all measures (measures of audibility, segmental and suprasegmental perception and vocabulary). Lastly, although age is not significantly correlated with measures of audibility, it is significantly correlated with all other outcome measures. CONCLUSIONS: The absence of a significant correlation between audibility and segmental speech perception might be attributed to overall audibility being maximized through well-fit HAs. The significant correlation between low-frequency unaided audibility and suprasegmental measures is likely due to the strong, predominantly low-frequency nature of suprasegmental acoustic properties. Frequency resolution ability, via SMD performance, is significantly correlated with all outcomes and requires further investigation; its significant correlation with vocabulary suggests that linguistic ability may be partially related to frequency resolution ability. Last, all of the outcome measures are significantly correlated with age, suggestive of developmental effects.

The Effects of Auditory Contrast Tuning upon Speech Intelligibility.

We have previously identified neurons tuned to spectral contrast of wideband sounds in auditory cortex of awake marmoset monkeys. Because additive noise alters the spectral contrast of speech, contrast-tuned neurons, if present in human auditory cortex, may aid in extracting speech from noise. Given that this cortical function may be underdeveloped in individuals with sensorineural hearing loss, incorporating biologically-inspired algorithms into external signal processing devices could provide speech enhancement benefits to cochlear implantees. In this study we first constructed a computational signal processing algorithm to mimic auditory cortex contrast tuning. We then manipulated the shape of contrast channels and evaluated the intelligibility of reconstructed noisy speech using a metric to predict cochlear implant user perception. Candidate speech enhancement strategies were then tested in cochlear implantees with a hearing-in-noise test. Accentuation of intermediate contrast values or all contrast values improved computed intelligibility. Cochlear implant subjects showed significant improvement in noisy speech intelligibility with a contrast shaping procedure.

The Effects of Preprocessing Strategies for Pediatric Cochlear Implant Recipients.

BACKGROUND: Cochlear implants (CIs) have been shown to improve children's speech recognition over traditional amplification when severe-to-profound sensorineural hearing loss is present. Despite improvements, understanding speech at low-level intensities or in the presence of background noise remains difficult. In an effort to improve speech understanding in challenging environments, Cochlear Ltd. offers preprocessing strategies that apply various algorithms before mapping the signal to the internal array. Two of these strategies include Autosensitivity Control™ (ASC) and Adaptive Dynamic Range Optimization (ADRO(®)). Based on the previous research, the manufacturer's default preprocessing strategy for pediatrics' everyday programs combines ASC + ADRO(®). PURPOSE: The purpose of this study is to compare pediatric speech perception performance across various preprocessing strategies while applying a specific programming protocol using increased threshold levels to ensure access to very low-level sounds. RESEARCH DESIGN: This was a prospective, cross-sectional, observational study. Participants completed speech perception tasks in four preprocessing conditions: no preprocessing, ADRO(®), ASC, and ASC + ADRO(®). STUDY SAMPLE: Eleven pediatric Cochlear Ltd. CI users were recruited: six bilateral, one unilateral, and four bimodal. INTERVENTION: Four programs, with the participants' everyday map, were loaded into the processor with different preprocessing strategies applied in each of the four programs: no preprocessing, ADRO(®), ASC, and ASC + ADRO(®). DATA COLLECTION AND ANALYSIS: Participants repeated consonant-nucleus-consonant (CNC) words presented at 50 and 70 dB SPL in quiet and Hearing in Noise Test (HINT) sentences presented adaptively with competing R-Space(TM) noise at 60 and 70 dB SPL. Each measure was completed as participants listened with each of the four preprocessing strategies listed above. Test order and conditions were randomized. A repeated-measures analysis of was used to compare each preprocessing strategy for the group. Critical differences were used to determine significant score differences between each preprocessing strategy for individual participants. RESULTS: For CNC words presented at 50 dB SPL, the group data revealed significantly better scores using ASC + ADRO(®) compared to all other preprocessing conditions while ASC resulted in poorer scores compared to ADRO(®) and ASC + ADRO(®). Group data for HINT sentences presented in 70 dB SPL of R-Space(TM) noise revealed significantly improved scores using ASC and ASC + ADRO(®) compared to no preprocessing, with ASC + ADRO(®) scores being better than ADRO(®) alone scores. Group data for CNC words presented at 70 dB SPL and adaptive HINT sentences presented in 60 dB SPL of R-Space(TM) noise showed no significant difference among conditions. Individual data showed that the preprocessing strategy yielding the best scores varied across measures and participants. CONCLUSIONS: Group data reveal an advantage with ASC + ADRO(®) for speech perception presented at lower levels and in higher levels of background noise. Individual data revealed that the optimal preprocessing strategy varied among participants, indicating that a variety of preprocessing strategies should be explored for each CI user considering his or her performance in challenging listening environments.

Evaluation of hearing aid frequency response fittings in pediatric and young adult bimodal recipients.

BACKGROUND: A coordinated fitting of a cochlear implant (CI) and contralateral hearing aid (HA) for bimodal device use should emphasize balanced audibility and loudness across devices. However, guidelines for allocating frequency information to the CI and HA are not well established for the growing population of bimodal recipients. PURPOSE: The study aim was to compare the effects of three different HA frequency responses, when fitting a CI and an HA for bimodal use, on speech recognition and localization in children/young adults. Specifically, the three frequency responses were wideband, restricted high frequency, and nonlinear frequency compression (NLFC), which were compared with measures of word recognition in quiet, sentence recognition in noise, talker discrimination, and sound localization. RESEARCH DESIGN: The HA frequency responses were evaluated using an A B1 A B2 test design: wideband frequency response (baseline-A), restricted high-frequency response (experimental-B1), and NLFC-activated (experimental-B2). All participants were allowed 3-4 weeks between each test session for acclimatization to each new HA setting. Bimodal benefit was determined by comparing the bimodal score to the CI-alone score. STUDY SAMPLE: Participants were 14 children and young adults (ages 7-21 yr) who were experienced users of bimodal devices. All had been unilaterally implanted with a Nucleus CI24 internal system and used either a Freedom or CP810 speech processor. All received a Phonak Naida IX UP behind-the-ear HA at the beginning of the study. DATA COLLECTION AND ANALYSIS: Group results for the three bimodal conditions (HA frequency response with wideband, restricted high frequency, and NLFC) on each outcome measure were analyzed using a repeated measures analysis of variance. Group results using the individual "best bimodal" score were analyzed and confirmed using a resampling procedure. Correlation analyses examined the effects of audibility (aided and unaided hearing) in each bimodal condition for each outcome measure. Individual data were analyzed for word recognition in quiet, sentence recognition in noise, and localization. Individual preference for the three bimodal conditions was also assessed. RESULTS: Group data revealed no significant difference between the three bimodal conditions for word recognition in quiet, sentence recognition in noise, and talker discrimination. However, group data for the localization measure revealed that both wideband and NLFC resulted in significantly improved bimodal performance. The condition that yielded the "best bimodal" score varied across participants. Because of this individual variability, the "best bimodal" score was chosen for each participant to reassess group data within word recognition in quiet, sentence recognition in noise, and talker discrimination. This method revealed a bimodal benefit for word recognition in quiet after a randomization test was used to confirm significance. The majority of the participants preferred NLFC at the conclusion of the study, although a few preferred a restricted high-frequency response or reported no preference. CONCLUSIONS: These results support consideration of restricted high-frequency and NLFC HA responses in addition to traditional wideband response for bimodal device users.

The effects of audibility and novel word learning ability on vocabulary level in children with cochlear implants.

OBJECTIVES: A novel word learning (NWL) paradigm was used to explore underlying phonological and cognitive mechanisms responsible for delayed vocabulary level in children with cochlear implants (CIs). METHODS: One hundred and one children using CIs, 6-12 years old, were tested along with 47 children with normal hearing (NH). Tests of NWL, receptive vocabulary, and speech perception at 2 loudness levels were administered to children with CIs. Those with NH completed the NWL task and a receptive vocabulary test. CI participants with good audibility (GA) versus poor audibility (PA) were compared on all measures. Analysis of variance was used to compare performance across the children with NH and the two groups of children with CIs. Multiple regression analysis was employed to identify independent predictors of vocabulary outcomes. RESULTS: Children with CIs in the GA group scored higher in receptive vocabulary and NWL than children in the PA group, although they did not reach NH levels. CI-aided pure tone threshold and performance on the NWL task predicted independent variance in vocabulary after accounting for other known predictors. DISCUSSION: Acquiring spoken vocabulary is facilitated by GA with a CI and phonological learning and memory skills. Children with CIs did not learn novel words at the same rate or achieve the same receptive vocabulary levels as their NH peers. Maximizing audibility for the perception of speech and direct instruction of new vocabulary may be necessary for children with CIs to reach levels seen in peers with NH.

Interdependence of linguistic and indexical speech perception skills in school-age children with early cochlear implantation.

OBJECTIVES: This study documented the ability of experienced pediatric cochlear implant (CI) users to perceive linguistic properties (what is said) and indexical attributes (emotional intent and talker identity) of speech, and examined the extent to which linguistic (LSP) and indexical (ISP) perception skills are related. Preimplant-aided hearing, age at implantation, speech processor technology, CI-aided thresholds, sequential bilateral cochlear implantation, and academic integration with hearing age-mates were examined for their possible relationships to both LSP and ISP skills. DESIGN: Sixty 9- to 12-year olds, first implanted at an early age (12 to 38 months), participated in a comprehensive test battery that included the following LSP skills: (1) recognition of monosyllabic words at loud and soft levels, (2) repetition of phonemes and suprasegmental features from nonwords, and (3) recognition of key words from sentences presented within a noise background, and the following ISP skills: (1) discrimination of across-gender and within-gender (female) talkers and (2) identification and discrimination of emotional content from spoken sentences. A group of 30 age-matched children without hearing loss completed the nonword repetition, and talker- and emotion-perception tasks for comparison. RESULTS: Word-recognition scores decreased with signal level from a mean of 77% correct at 70 dB SPL to 52% at 50 dB SPL. On average, CI users recognized 50% of key words presented in sentences that were 9.8 dB above background noise. Phonetic properties were repeated from nonword stimuli at about the same level of accuracy as suprasegmental attributes (70 and 75%, respectively). The majority of CI users identified emotional content and differentiated talkers significantly above chance levels. Scores on LSP and ISP measures were combined into separate principal component scores and these components were highly correlated (r = 0.76). Both LSP and ISP component scores were higher for children who received a CI at the youngest ages, upgraded to more recent CI technology and had lower CI-aided thresholds. Higher scores, for both LSP and ISP components, were also associated with higher language levels and mainstreaming at younger ages. Higher ISP scores were associated with better social skills. CONCLUSIONS: Results strongly support a link between indexical and linguistic properties in perceptual analysis of speech. These two channels of information appear to be processed together in parallel by the auditory system and are inseparable in perception. Better speech performance, for both linguistic and indexical perception, is associated with younger age at implantation and use of more recent speech processor technology. Children with better speech perception demonstrated better spoken language, earlier academic mainstreaming, and placement in more typically sized classrooms (i.e., >20 students). Well-developed social skills were more highly associated with the ability to discriminate the nuances of talker identity and emotion than with the ability to recognize words and sentences through listening. The extent to which early cochlear implantation enabled these early-implanted children to make use of both linguistic and indexical properties of speech influenced not only their development of spoken language, but also their ability to function successfully in a hearing world.

A longitudinal study of speech perception skills and device characteristics of adolescent cochlear implant users.

BACKGROUND: For pediatric cochlear implant (CI) users, CI processor technology, map characteristics, and fitting strategies are known to have a substantial impact on speech perception scores at young ages. It is unknown whether these benefits continue over time as these children reach adolescence. PURPOSE: To document changes in CI technology, map characteristics, and speech perception scores in children between elementary grades and high school, and to describe relations between map characteristics and speech perception scores over time. RESEARCH DESIGN: A longitudinal design with participants 8-9-yr-old at session 1 and 15-18-yr-old at session 2. STUDY SAMPLE: Participants were 82 adolescents with unilateral CIs, who are a subset of a larger longitudinal study. Mean age at implantation was 3.4 yr (range: 1.7-5.4), and mean duration of device use was 5.5 yr (range: 3.8-7.5) at session 1 and 13.3 yr (range: 10.9-15) at session 2. DATA COLLECTION AND ANALYSIS: Speech perception tests at sessions 1 and 2 were the Lexical Neighborhood Test (LNT) presented at 70 dB SPL (LNT-70) and Bamford-Kowal-Bench sentences in quiet (BKB-Q) presented at 70 dB SPL. At session 2, the LNT was also administered at 50 dB SPL (LNT-50), and BKB sentences were administered in noise with a +10 dB SNR (BKB-N). CI processor technology type and CI map characteristics (coding strategy, number of electrodes, threshold levels, and comfort levels) were obtained at both sessions. Electrical dynamic range was computed, and descriptive statistics, correlations, and repeated-measures ANOVAs were employed. RESULTS: Participants achieved significantly higher LNT and BKB scores, at 70 dB SPL, at ages 15-18 than at ages 8-9 yr. Forty-two participants had 1-3 electrodes either activated or deactivated in their map between test sessions, and 40 had no change in number of active electrodes (mean change: -0.5; range: -3 to +2). After conversion from arbitrary clinical map units to charge-per-phase in nanocoulombs (nC), no significant difference was found for T levels across time. Average comfort levels (C levels) decreased by 19 nC. Seventy-three participants (89%) upgraded their CI processor technology type. At both sessions, significant correlations were found between electrical dynamic range (EDR) and all speech perception measures except LNT-50 (r range: .31 to .47; p < 0.01). Similarly, significant correlations were also found between C levels and all speech perception measures (r range: .29 to .49; p < 0.01). At session 2, a significant correlation was found between processor technology type and the LNT-50 scores (r = .38; p < 0.01). CONCLUSIONS: Significant improvement in speech scores was observed between elementary grades and high school for children who had used a CI since preschool. On average, T levels (nC) and electrode function remained stable for these long-term pediatric users. Analyses of maps did not allow for the determination of the exact cause of C level reductions, though power limitations in new processor systems and changes in perceived loudness over time are possible. Larger EDRs and higher C levels were associated with better speech scores. Newer speech processor technology was associated with better speech scores at a softer level.

Factors contributing to speech perception scores in long-term pediatric cochlear implant users.

OBJECTIVES: The objectives of this report are to (1) describe the speech perception abilities of long-term pediatric cochlear implant (CI) recipients by comparing scores obtained at elementary school (CI-E, 8 to 9 yrs) with scores obtained at high school (CI-HS, 15 to 18 yrs); (2) evaluate speech perception abilities in demanding listening conditions (i.e., noise and lower intensity levels) at adolescence; and (3) examine the relation of speech perception scores to speech and language development over this longitudinal timeframe. DESIGN: All 112 teenagers were part of a previous nationwide study of 8- and 9-yr-olds (N = 181) who received a CI between 2 and 5 yrs of age. The test battery included (1) the Lexical Neighborhood Test (LNT; hard and easy word lists); (2) the Bamford Kowal Bench sentence test; (3) the Children's Auditory-Visual Enhancement Test; (4) the Test of Auditory Comprehension of Language at CI-E; (5) the Peabody Picture Vocabulary Test at CI-HS; and (6) the McGarr sentences (consonants correct) at CI-E and CI-HS. CI-HS speech perception was measured in both optimal and demanding listening conditions (i.e., background noise and low-intensity level). Speech perception scores were compared based on age at test, lexical difficulty of stimuli, listening environment (optimal and demanding), input mode (visual and auditory-visual), and language age. RESULTS: All group mean scores significantly increased with age across the two test sessions. Scores of adolescents significantly decreased in demanding listening conditions. The effect of lexical difficulty on the LNT scores, as evidenced by the difference in performance between easy versus hard lists, increased with age and decreased for adolescents in challenging listening conditions. Calculated curves for percent correct speech perception scores (LNT and Bamford Kowal Bench) and consonants correct on the McGarr sentences plotted against age-equivalent language scores on the Test of Auditory Comprehension of Language and Peabody Picture Vocabulary Test achieved asymptote at similar ages, around 10 to 11 yrs. CONCLUSIONS: On average, children receiving CIs between 2 and 5 yrs of age exhibited significant improvement on tests of speech perception, lipreading, speech production, and language skills measured between primary grades and adolescence. Evidence suggests that improvement in speech perception scores with age reflects increased spoken language level up to a language age of about 10 yrs. Speech perception performance significantly decreased with softer stimulus intensity level and with introduction of background noise. Upgrades to newer speech processing strategies and greater use of frequency-modulated systems may be beneficial for ameliorating performance under these demanding listening conditions.

Cochlear implant characteristics and speech perception skills of adolescents with long-term device use.

OBJECTIVE: Updated cochlear implant technology and optimized fitting can have a substantial impact on speech perception. The effects of upgrades in processor technology and aided thresholds on word recognition at soft input levels and sentence recognition in noise were examined. We hypothesized that updated speech processors and lower aided thresholds would allow improved recognition of soft speech without compromising performance in noise. STUDY DESIGN: 109 teenagers who had used a Nucleus 22-cochlear implant since preschool were tested with their current speech processor(s) (101 unilateral and 8 bilateral): 13 used the Spectra, 22 the ESPrit 22, 61 the ESPrit 3G, and 13 the Freedom. MAIN OUTCOME MEASURES: The Lexical Neighborhood Test (LNT) was administered at 70 and 50 dB SPL and the Bamford Kowal Bench sentences were administered in quiet and in noise. Aided thresholds were obtained for frequency-modulated tones from 250 to 4,000 Hz. Results were analyzed using repeated measures analysis of variance. RESULTS: Aided thresholds for the Freedom/3G group were significantly lower (better) than the Spectra/Sprint group. LNT scores at 50 dB were significantly higher for the Freedom/3G group. No significant differences between the 2 groups were found for the LNT at 70 or sentences in quiet or noise. CONCLUSION: Adolescents using updated processors that allowed for aided detection thresholds of 30 dB HL or better performed the best at soft levels. The BKB in noise results suggest that greater access to soft speech does not compromise listening in noise.