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ABSTRACT: Purpose: This study investigated factors contributing to auditory, speech, language, and reading outcomes
in children with prelingual deafness after 46 years of
multichannel cochlear implant use. The analysis controlled
for the effects of child, family, and implant characteristics
so that educational factors most conducive to maximum
implant benefit could be identified.
Method: The sample included 136 8- and 9-year-old children
from across the United States and Canada who were
implanted by age 5 with the Nucleus 22-channel implant.
Type and amount of educational intervention since implantation constituted the independent variables. The dependent
variable was performance on a battery of tests of speech
perception, speech production, language, and reading
administered 46 years postimplant. Characteristics of the
child, the family, and the implant itself constituted interven-
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LANGUAGE , SPEECH ,
AND
H EARING SERVICES
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METHOD
Participants
Over a 4-year period, 180 8- and 9-year-old children
from 33 different states and 5 Canadian provinces came to
St. Louis to attend the Cochlear Implant Summer Research
Camp. This preliminary report describes 136 children who
were tested during the first 3 years of data collection.
Participants were selected to be as homogeneous as
possible on a number of key factors known to affect
performance postimplant. Characteristics of these participants are summarized in Table 1. These children all
received their implants when the candidacy requirements
included no observable benefit from conventional amplification. Thus, none of these children exhibited any open-set
speech perception ability with hearing aids before receiving
an implant. The participants do not represent any single
educational program or method, but rather come from the
full range of educational settings available across the
United States and Canada.
Procedure
Approximately 15 children, accompanied by a parent,
were included in each data collection camp session. All
expenses were paid, including transportation, hotel accommodations for 4 nights, and daily entertainment activities.
Testing took place 2 hours each day for 3 days. All
children were tested under similar conditions with a
consistent group of examiners on an identical battery of
tests. Children were tested individually in their hotel
rooms, which were converted to testing suites each morning. The parents attended educational seminars during this
time and completed questionnaires and signed release forms
for questionnaires sent to implant centers and clinicians. In
the afternoon, families participated in planned recreational
activities. Three categories of measures were obtained: (a)
intervening variables that were controlled in the analysis,
(b) independent educational variables that were the focus of
the study, and (c) outcome measures that represented each
childs auditory, speech, language, and reading abilities.
Intervening variables. These are factors that are either
known or suspected to affect speech and language developTable 1. Sample characteristics for 136 subjects.
SD
Minimum
Maximum
9;0
0;4
3;6
102
5;6
3;0
18
0;6
0;9
0;9
15
0;9
1;8
2.86
8;0
0
1;10
65
3;9
0
6
9;11
3;0
5;2
136
7;6
5;2
22
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L ANGUAGE, SPEECH,
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4
3
2
1
0
Year 1
Year 2
Year 3
Current Year
Figure 2. Clinicians returning therapy questionnaires described in terms of their prior experience
with children who are deaf and children who use cochlear implants (CIs).
60
Percentage of Clinicians
50
40
No CI experience
30
CI experience
20
10
0
0
15
610
>10
15
610
>10
175
Median Rating
Daily
Weekly
Monthly
Rarely
Never
Year 1
Year 2
Year 3
Current Year
Figure 4. Percentage of children enrolled in no school program, public school program, private
school program, or both public and private school programs at the time a cochlear implant was
fitted (at CI) and each of 4 years thereafter.
Percentage of Children
100
80
None
Public
60
Private
40
Both
20
0
at CI
Year 1
Year 2
Year 3
Current Year
Figure 5. Percentage of children enrolled in no program, special education class, part-day mainstream (MS) class, or full-day mainstream class at the time a cochlear implant was fitted (at CI) and
each of 4 years thereafter.
Percentage of Children
80
None
60
Special Ed
Partial MS
40
Full MS
20
0
at CI
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L ANGUAGE, SPEECH,
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Year 1
Year 2
HEARING SERVICES
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Year 3
Current Year
1
Mostly sign
2
3
Speech & sign Speech emphasis
4
Cued speech
Total Communication
Increasing speech emphasis
5
Auditoryoral
6
Auditoryverbal
Oral Communication
Increasing auditory emphasis
Figure 6. Classroom communication mode rating for each of 136 subjects averaged over 5 years plotted in order of increasing
emphasis on speech and auditory skill development.
Mode Average
5
4
Total Communication
Oral Communication
2
1
0
Subjects (N = 136)
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Table 3. Test battery and factor loadings (FL) for composite score on each outcome.
Speech
perception
FL
ESP
WIPI
LNT
MLNT
BKB
VidSPAC
CHIVE
ARQ
.88
.88
.93
.92
.92
.78
.94
.69
Speech
production
McG-HC
McG-LC
% consonants
% vowels
Dyalog
% plosives
SPQ
FL
.93
.91
.95
.68
.87
.73
.89
Spoken
language
FL
IPSyn NPa
IPSyn VPa
IPSyn QNa
IPSyn SSa
Typesa
Morpha
Wd/Utta
Fluencya
.87
.95
.67
.93
.96
.83
.89
.87
Total
language
FL
Reading
FL
IPSyn NP b
IPSyn VP b
IPSyn QN b
IPSyn SS b
Typesb
Morphb
Wd/Uttb
NAS
WISC-sim
TACL-wc
TACL-gm
TACL-es
.79
.89
.52
.89
.85
.82
.89
.83
.79
.56
.62
.77
PIAT rec
PIAT comp
WRMT wa
RHYME
LD
.95
.90
.88
.59
.65
Note. Speech Perception: ESP = Early Speech Perception Test for Profoundly Deaf Children (Moog & Geers, 1990); WIPI = Word Intelligibility by Picture Identification (Ross & Lerman, 1971); LNT = Lexical Neighborhood Test (Kirk, Pisoni, & Osberger, 1995); MLNT =
Multisyllabic Lexical Neighborhood Test (Kirk, Pisoni, & Osberger, 1995); BKB = Bamford Kowal Bench Sentences (Bamford & Wilson,
1979); VidSPAC = Video Game Test of Speech Pattern Contrast Perception (Boothroyd, 1997); CHIVE = Childrens Visual Enhancement Test
(Tye-Murray & Geers, 1997); ARQ = Auditory Responsiveness Questionnaire.
Speech Production: McG = McGarr sentences (McGarr, 1983); HC = high context; LC = low context; Dyalog = Dyalog Communication
Analysis (Erber & Weiner, 1997); SPQ = Use of Speech Questionnaire.
Spoken/Total Language: IPSyn = Index of Productive Syntax (Scarborough, 1990); NP = noun phrases; VP = verb phrases; QN = questions/
negatives; SS = sentence structures; NAS = Narrative Ability Score (Crosson & Geers, 2001); WISC-III = Wechsler Intelligence Scale for
Children, Third Edition (Wechsler, 1991); TACL = Test for Auditory Comprehension of LanguageRevised (Carrow, 1985); wc = word
classes; gm = grammatical morphemes; es = elaborated sentences.
Reading: PIAT = Peabody Individual Achievement TestRevised (Dunn & Markwardt, 1989); Rec: = reading recognition; Comp = reading
comprehension; WRMT = Woodcock Reading Mastery TestsRevised (Woodcock, 1987); wa = word attack; LD = lexical decision task.
a
Based on spoken language sample; bBased on spoken and signed language sample.
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L ANGUAGE, SPEECH,
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RESULTS
The purpose of the analysis was to assess the effects of
the independent (i.e., educational) variables on each of the
five dependent variables after variance as a result of
intervening variables had been removed. Linear regression
was used to partial out the variance in each outcome that
was associated first with child and family characteristics,
then with implant characteristics, and finally with the
remaining variance predicted by the educational variables.
Results for child and family characteristics are summarized
in Table 4. Standardized coefficients represent the magnitude of contribution of each intervening variable to an
outcome after variance as a result of all of the other listed
variables has been accounted for. The total variance
accounted for by child and family characteristics ranged
from 11% for spoken language to 20% for reading.
Performance IQ on the WISCIII (Wechsler, 1991) contributed significant variance to all outcomes and was the only
significant independent predictor among the child and
family characteristics in speech perception, speech production, and spoken language. Older children (i.e., 9-year-olds)
achieved higher reading scores than younger children (i.e.,
8-year-olds), and children who lost their hearing later
Age
Age at onset
Age at implant
Performance IQ
Family size
Parents education
Total variance (R2)
Speech
perception
Speech
production
.10
.03
.07
.32***
.15
.08
.09
.07
.10
.29***
.15
.07
18%
15%
Spoken
language
Total
language
.00
.11
.07
.20*
.16
.13
.06
.20*
.05
.21*
.17*
.20*
11%
17%
Reading
.19*
.17*
.08
.34***
.11
.13
20%
(df 6,129)
*p < .05, **p < .01, ***p < .001
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Speech
perception
Duration of SPeak
# of active electrodes
Dynamic range
Loudness growth
Added variance (R2)
Speech
production
.23**
.24***
.27***
.17*
.22**
.16*
.21**
.24**
26%
22%
Spoken
language
.19*
.22**
.20**
.24**
23%
Total
language
Reading
.25**
.18*
.21**
.18*
.20*
.16*
.23**
.15
21%
17%
Total
language
Reading
.12
.02
.07
.07
.18*
.14
.06
.02
.05
.06
.23**
.18*
(df 4,131)
*p < .05, **p < .01, ***p < .001
Independent
variables
Speech
perception
Speech
production
Spoken
language
Hours of therapy
Therapist experience
Parent participation
School setting a
Type of class b
Communication mode
.13
.03
.04
.02
.06
.37***
.13
.05
.04
.12
.13
.30***
.08
.01
.06
.01
.13*
.30***
16%
18%
10%
5%
(df 6,129)
a
Public/private; bMainstream/special education.
*p < .05, **p < .01, ***p < .001
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7%
CONCLUSION
Children who receive cochlear implants before 5 years
of age are presented with auditory information at a crucial
time for speech and language development. The extent to
which a child will use this information to achieve speech,
language, and reading competence is affected by a variety
of factors: (a) those that the child brings to the learning
environment, (b) those that are provided by the implant
itself, and (c) those that are provided by parents and
professionals conducting the childs rehabilitation program.
The results of this study help us to understand the importance of each of these components.
all of the reported data were derived from the only implant
device available when these children were first implanted
(the Nucleus 22-electrode model from Cochlear Corporation) means that anything with fewer than 20 electrodes
represents a less than optimal device. Alternative cochlear
implants that are currently available (e.g., the Clarion and
Med-El devices) use different speech processing strategies
on differing numbers of electrodes. A complete insertion of
the electrode array and a map that activates all available
electrodes will go a long way toward promoting optimal
performance.
The audiologist who programs the cochlear implant
makes a particularly important contribution to the childs
potential successful outcome with the device. Once the
processing strategy and the number of active electrodes
have been maximized, it is the audiologists role to achieve
the most appropriate and balanced map possible for that
child. A well-fitted map, as evidenced by a wide dynamic
range and optimal growth of loudness characteristics,
contributed substantial variance for all outcomes. This is a
particularly important consideration in the mapping of
newly implanted infants, who may not be able to respond
to traditional mapping techniques.
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REFERENCES
Bamford, J. M., & Wilson, I. M. (1979). Methodological
considerations and practical aspects of the BKB sentence lists.
In R. J. Bench & J. M. Bamford (Eds.), Speech-hearing tests
and the spoken language of hearing impaired children (pp. 147
187). London: Academic Press.
L ANGUAGE, SPEECH,
AND
ACKNOWLEDGMENTS
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HEARING SERVICES
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Tye-Murray, N., & Geers, A. (1997). Childrens Visual Enhancement Test. Central Institute for the Deaf Periodic Progress
Report, 33, 912.
Uchanski, R. M., Torretta, G., Geers, A., & Tobey, E. (1999).
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speech for children using cochlear implants. Journal of the
Acoustical Society of America, 106(4), 2213.
Waltzman, S. B., & Cohen, N. (1998). Cochlear implantation in
children younger than two years old. American Journal of
Otology, 19, 158162.
Wechsler, D. (1991). Wechsler Intelligence Scale for Children (3rd
ed.). San Antonio, TX: Psychological/Harcourt Brace.
Woodcock, R. W. (1987). Woodcock Reading Mastery Tests
Revised. Allen, TX: DLM Teaching Resources.
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