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Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2014) 15, 29–35

Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied


Sciences
www.ejentas.com

ORIGINAL ARTICLE

Psycholinguistic abilities in cochlear implant


and hearing impaired children
Hatem Ezzeldin Hassan a,b,*, Sally Taher Kheir Eldin c,
Rasha Mohamed Al Kasaby d,e

a
Otorhinolaryngology Department, Sohag University, Egypt
b
King Fahd Hospital, Jeddah, Saudi Arabia
c
Otorhinolaryngology Department, Ain Shams University, Egypt
d
Otorhinolaryngology Department, Mansoura University, Egypt
e
Military Hospital, Riyadh, Saudi Arabia

Received 20 September 2013; accepted 14 December 2013


Available online 17 January 2014

KEYWORDS Abstract Background: Many congenitally sensorineural hearing loss (SNHL) children and
Psycholinguistic; cochlear implant (CI) recipients develop near-normal language skills. However, there is a wide var-
Cochlear implant; iation in individual outcomes following cochlear implantation, or using hearing aids. Some CI
Language disorders; recipients or Hearing aids users never develop useable speech and oral language skills. The causes
Hearing of this enormous variation in outcomes are only partly understood at the present time. So, the aim
of this study was to assess the psycholinguistic skills in Arabic speaking children with either SNHL
or CI in comparison to normal controls in order to estimate the nature and extent of any specific
deficit in these children that could explain the different prognostic results of language intervention.
Subjects and methods: Three groups were selected, according to Language test, Pure tone audi-
ometry (PTA) & Auditory brain stem response (ABR). Group I included fourteen children with
severe and/or severe to profound SNHL aided with proper hearing aids. Group II consisted of four-
teen children with CI (MED-EL and Nucleus) and group III included fourteen children with normal
hearing. Receptive, Expressive and total language quotients were calculated using the Arabic
Language test. Assessment of psycholinguistic abilities was done using the Arabic version of the
Illinois Test of Psycholinguistic abilities.

* Corresponding author at: King Fahd Hospital, Jeddah, Saudi


Arabia. Mobile: +966 594183458.
E-mail address: hezzm268@yahoo.com (Hatem Ezzeldin Hassan).
Peer review under responsibility of Egyptian Society of Ear, Nose,
Throat and Allied Sciences.

Production and hosting by Elsevier

2090-0740 ª 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2013.12.006
30 H.E. Hassan et al.

Conclusion: HI individuals have poor auditory short-term memory (A-STM) in comparison to


normal hearing individuals. Also, HI individuals have visual short-term memory (V-STM) better
than normal hearing individuals. So, multisensory training is needed both in therapy sessions
and classrooms with more focus on visual stimuli.
ª 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and
Allied Sciences.

1. Introduction iation in outcomes of rehabilitation of HI & CI regarding A-


STM & V-STM.
Many congenitally sensorineural hearing loss (SNHL) children
1.1. Aim of the work
and cochlear implant (CI) recipients develop near-normal lan-
guage skills. However, there is wide variation in individual out-
comes following cochlear implantation, or using hearing aids.1 The aim of this study was to assess the Psycholinguistic skills
Some CI recipients or Hearing aids users never develop useable in Arabic speaking children with either SNHL or CI in com-
speech and oral language skills. The causes of this enormous parison to controls in order to estimate the nature and extent
variation in outcomes are only partly understood at the pres- of any specific deficit in these children that could explain the
ent time.2 Unfortunately, deaf students often have been found different prognostic results of language intervention.
to have lower vocabulary skills than hearing age-matched
peers. The size of their vocabulary tends to be smaller, the rate 1.2. Subjects and methods
in which they acquire new vocabulary is slower, and they less
easily develop new word meaning acquisition processes (Pisoni This study was conducted on children presented with delayed
et al., 2000). language development to Phoniatrics clinic, King Fahd Hospi-
Several researchers have pointed out that early identifica- tal Jeddah, during the period from October 2011 to July 2012.
tion of hearing loss (HL) has a positive effect on vocabulary Three groups were selected, according to Language test,
development. The result of early intervention services pro- Pure tone audiometry (PTA) & Auditory brain stem response
vides support for both language and cognitive development. (ABR). Group I included fourteen children with severe and/or
Aside from studies of early vocabulary development as part severe to profound SNHL aided with proper hearing aids.
of language acquisition, studies of vocabulary in deaf learn- Group II consisted of fourteen children with CI (MED-EL
ers have focused on the relation between vocabulary and & Nuleus) and group III included fourteen children with nor-
reading.3 mal hearing.
Psycholinguistic abilities, both auditory short-term memo- All children included in this study were subjected to a com-
ries (Auditory sequential memory, Sound blending, Auditory prehensive language assessment protocol.6
closure, Auditory association and Verbal expression) and Vi-
sual short term memories (Visual sequential memory, Visual - Patient’s interview.
reception, Visual closure and Manual expression) are impor- - Audiological evaluation including Auditory Brain Stem
tant predictors for language development in normal children Response (ABR), Otoacoustic Emissions (OAEs) and
and children with disabilities. Cochlear Microphonic (CM).
Surowieck et al.4 claimed that many children using cochlear - Psychometric evaluation by using Wechsler intelligence
implants are able to hear fine differences between speech scale.8
sounds but are not progressing as wel1 as expected in receptive - Objective language assessment was done using Standard
language ability. There is strong evidence from teachers that Arabic language test to calculate Receptive, Expressive
some children using cochlear implants have poor short-term and total language quotients.6
auditory memory ability, which may be impeding their lan- - Assessment of psycholinguistic abilities was done using the
guage development. Temporal ordering and short-term mem- Arabic version of the Illinois Test of Psycholinguistic
ory storage capacity involve higher order processing. Severe Abilities.7
auditory deprivation prior to implantation may have caused - Inclusion criteria: Individuals with severe and/or severe to
auditory processing deficits at a cortical level. profound SNHL, aided with proper hearing aids more than
When cochlear implant implantation will be carried out 5 years. Individuals using CI more than 5 years duration.
especially at the very critical period of language development - Exclusion criteria: Subjects with mental retardation (MR),
(before age of four), this will help the child, in his/her future below average mentality or any subject with behavioral
life, not only with his/her hearing skills and communication problems, pervasive developmental disorders or with audi-
but for his/her attention skills and behavior.5 The causes of tory neuropathy were excluded from the study.
these apparent differences in the success of treatment among
HI & CI children are poorly understood. Therefore, early iden- Children with Hearing Impairment (HI) were 8 boys and 6
tification, understanding the nature of the disorders and prop- girls. Their mean age was 8.3 ± 1.3 and age ranged from 6 to
er intervention is warranted. However, to our knowledge, there 12 years. The mean duration of H.As fitting was 5 ± 2 years.
have been no studies done to assess short term memory of Ara- Children with Cochlear Implant (CI) were 7 boys and 7
bic speaking children with HI and CI. In this study we tried to girls. The mean age was 7.9 ± 0.9 years and age ranged from
have answers for the former questions, why there is a wide var- 6 to 12.6 years. The mean duration of CI was 5 ± 1 year. Both
Psycholinguistic abilities in cochlear implant and hearing impaired children 31

groups of children (HI & CI) were attending regular individual 4- Manual expression: The child looks at 15 pictures of
language therapy sessions (two sessions per week, each session tools each presented lonely, and then he asked to imitate
for 30 minutes for 2 years). Family counseling was given to the the function of the tool manually.
parents every three months to enhance the language abilities of
the children. The raw scores for each subtest were used to drive scaled
Control group (normal hearing children) were 7 boys and 7 scores for each task. The raw scores for each subtest were used
girls. The mean age was 8.5 ± 1.2 and age ranged from 6 to to obtain the psycholinguistic age norms. The scaled scores are
11.9 years. These children were selected randomly from mem- linear transformation of raw scores for each subtest according
bers not suffering from any language and speech disorders. to the age levels.
They were selected from outpatient clinic; King Fahd Hospital Statistical methods: Statistical package for social Sciences
Jeddah, during the same period after taking their parents’ con- version 11 (SPSS, INC, Chicago, IL) under windows was used
sent and they were used as a reference for their language devel- for data entry and data analysis. Descriptive statistics were
opment. They were attending because of other communication done for continuous variables by mean, standard deviation
disorders as voice disorders. (± SD) and range; and for qualitative data by number and
percent. Student ‘t’ test and ANOVA test were used to com-
2. Procedures and clinical tools pare continuous variables in various groups. Pearson’s correla-
tion used to assess the association between the different
2.1. Assessment of short term memory parametric data. For all tests a probability (P) value less than
0.05 was considered significant.
Assessment of auditory and visual short term memory tasks
was done for all children, using the Arabic version of the Illi- 3. Results
nois Test of Psycholinguistic Abilities.7
Comparison between the hearing impairment group (HI), co-
2.1.1. Auditory short-term memory chlear implant group (CI) and control group regarding the dif-
ferent demographic data revealed insignificant statistically
differences (>0.05) between the three groups regarding the
1- Auditory sequential memory (ASM): Sequences of digits
age, gender distribution and IQ scores as shown in Table 1.
(1–9) were presented verbally to the child and the child
Results of the Arabic language test indicated that CI chil-
had to recall each digit sequence verbally. The task
dren showed significant differences (<0.05) in all language
was presented using both auditory and visual cues; the
parameters (Receptive, Expressive and total language age) in
child is allowed to see the face of the examiner.
comparison to HI children. Control group showed highly sig-
2- Sound blending (SB): Combinations of 2–6 CV syllables
nificant differences (<0.01) in comparison to both CI and HI
were used. The child had to repeat each syllable combi-
groups in all language parameters (Receptive, Expressive and
nation in the right order
total language age) as shown in Table 2.
3- Auditory closure: List of 30 words. The examiner pro-
Results of auditory short-term memory subtests revealed
nounced each word with one or more deleted sound.
significant differences (<0.05) in CI group in comparison to
The child had to pronounce each word correctly.
HI Group regarding all parameters of auditory short term
4- Auditory association: Incomplete phrases analogues. The
memory (sound blending, auditory association, auditory clo-
child had to complete the missed parts of this analogue
sure and verbal expression). Also there were highly significant
verbally.
differences (<0.01) between control group and CI and HI
5- Verbal expression: 5 different objects were used and the
groups in all auditory short term memory, as shown in Table 3.
child had to give full description of each object alone.
Results of visual short-term memory subtests revealed
insignificant differences (>0.05) between HI group and CI
group in all parameters of visual short memory (Visual sequen-
2.1.2. Assessment of Visual short-term memory
tial, visual reception, visual closure and manual expression).
However, there were significant differences (<0.05) in all sub-
1- Visual sequential memory (VSM): Sequences of 2–8 tests of visual short memory (Visual sequential, visual recep-
abstract symbols presented to the child for 5 seconds. tion, visual closure and manual expression) between HI and
CI groups in comparison to control group as shown in Table 4.

4. Discussion

The child had to place the plates in the right order. The world we live in is overwhelmingly rich and complex. As
2- Visual reception: The child sees one picture for 3 seconds human agents living in such a world we are constantly bom-
and he had to choose the one related to the former one. barded with large amounts of sensory information through
3- Visual closure: Sheets of pictures. The examiner named a multiple channels such as audition and vision. The outcome
picture of an object, while the child was looking at it, of language acquisition and learning is much different in hear-
then the child had to look at the full sheet of pictures ing impaired children and normal hearing individuals, some
and point to the biggest number of pictures similar to hearing impaired and cochlear implant children showed con-
the former one. siderable achievement regarding language development and
32 H.E. Hassan et al.

Table 1 Comparison between the hearing impairment groups (HI), cochlear implant group (CI) and control group regarding the
different demographic data.
Variables HI CI Control ANOVA
Mean ± SD Mean ± SD Mean ± SD P value
Chronological age (years) 8.3 ± 1.3 7.8 ± 0.9 8.5 ± 1.2 >0.05
Gender
Boys 8 (57.2%) 7 (50%) 7 (50%) >0.05
Girls 6 (42.8%) 7 (50%) 7 (50%)
IQ 100.5 ± 6 102.2 ± 5 101.9 ± 4 >0.05
There were no statistically differences (>0.05) between the three groups regarding the age, gender distribution and IQ scores.

Table 2 Comparison between the hearing impairment group (HI), cochlear implant group (CI) and control group regarding
Language assessment.
Variables HI CI Control ANOVA t-Test
Mean ± SD Mean ± SD Mean ± SD P value P value
Receptive language quotient 55.5 ± 6 75.3 ± 4 98.2 ± 6 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
Expressive language quotient 53.4 ± 4 71.7 ± 5 97.8 ± 4 <0.001** <0.05 * (a)
<0.001** (b)
<0.001* (c)
Total language quotient 54.7 ± 4 73.2 ± 3 97.3 ± 5 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
(a) HI vs. CI, (b) HI vs. control, (c) CI vs. control.
*
Significant.
**
Highly significant.

Table 3 Comparison between the hearing impairment group (HI), cochlear implant group (CI) and control group regarding auditory
short-term memory subtests.
Variables HI CI Control ANOVA t-Test
Mean ± SD Mean ± SD Mean ± SD P (sign.) P (sign.)
Auditory sequential memory 33 ± 2 34 ± 6 40.4 ± 5 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
Sound blending 34 ± 6 35 ± 2 43 ± 4 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
Auditory closure 27 ± 2 29 ± 6 37 ± 3 <0.001** <0.05 (a)
<0.001** (b)
<0.001** (c)
Auditory association 26 ± 4 30 ± 3 42 ± 5 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
Verbal expression 24 ± 3 27 ± 2 49 ± 2 <0.001** <0.05 * (a)
<0.001** (b)
<0.001** (c)
(a) HI vs. CI, (b) HI vs. control, (c) CI vs. control.
*
Significant.
**
Highly significant.
Psycholinguistic abilities in cochlear implant and hearing impaired children 33

Table 4 Comparison between the hearing impairment group (HI), cochlear implant group (CI) and control group regarding visual
short-term memory subtests.
Variables HI CI Control ANOVA test t-Test
Mean ± SD Mean ± SD Mean ± SD P value P value
Visual sequential memory 47 ± 3 46 ± 4 36 ± 4 <0.05* >0.05 (a)
<0.05* (b)
<0.05* (c)
Visual reception 45 ± 2 44 ± 4 34 ± 6 <0.05* >0.05 (a)
<0.05* (b)
<0.05* (c)
Visual closure 64 ± 4 47 ± 2 37 ± 1 <0.05* >0.05 (a)
<0.05** (b)
<0.05** (c)
Manual expression 46 ± 3 46 ± 5 38 ± 3 <0.05* >0.05 (a)
<0.05* (b)
<0.05* (c)
(a) HI vs. CI, (b) HI vs. control, (c) CI vs. control.
*
Significant.
**
Highly significant.

academic achievement, others fail to reach satisfactory results development. Spencer and Marschark11 reported that Children
(Rose et al., 2008). Because of the wide variation between the with HI were found to have small size of their vocabulary, less
results, authors tried to investigate other parameters as audi- semantic skills, slower rate of acquiring new vocabulary and
tory short term memory and visual short term memory and less easily develop new word meaning acquisition processes.
their effects on language development and academic
achievement.
Rose et al. (2008) have examined the memory skills of co- 5. Findings of Auditory short term memory
chlear implant users. Children with cochlear implants have
been found to have shorter auditory digit spans compared to In the current study, auditory short term memory tasks (sound
their normal-hearing. Moreover, they mentioned that Children blending, auditory association, auditory closure and verbal
using cochlear implants have also been found to perform expression) were better in normal hearing children in compar-
worse than their normal-hearing on immediate memory tasks ison to CI & HI groups. These results coincide with that ob-
even when the stimuli are not presented auditory and recall tained by Bavelier12 who reported poor memory for
does not require a verbal response. sequential information among HI in relation to hearing indi-
In this study attention was directed toward auditory and vi- viduals. These findings may point to the fact that early lan-
sual short-term memories, which seems to be related to cogni- guage development may enhance different auditory memory
tive processing tasks & language development. Thus, all skills in HI individuals due to brain plasticity. Furthermore,
children of the three groups were selected to be free from introduction of verbal and non verbal materials to the child
any neurological, behavioral deficits and within average men- environment during infancy and early childhood has its effect
tality. In This study children with cochlear implantation were on the development of A-STM.
significantly better in all language skills in comparison with HI Laurie et al.13 stated that, from a theoretical standpoint,
children. However all language parameters were significantly emergence of auditory perceptual milestones in young children
lower in HI and CI groups in comparison to normal control would be expected to follow a trajectory of general perceptual
group. This finding could be explained by the increased ability development. This model describes the following three stages
of the children with CI to comprehend speech and improve of development: sensory primitives (Level I), which characterizes
their speech intelligibility in addition to faster acquisition of basic sensory perceion; perceptual representations (Level II),
speech production and language development. Aline et al.9 which represents complex coding at higher neural levels;
highlighted the advantages of CI over hearing aids. They sta- and higher order representations (Level III), which denotes
ted that cochlear implants were demonstrated to be the best cognitive/linguistic processing.
current alternative for bilateral severe or profound hearing However, Wilson et al.14 compared memory span perfor-
loss, achieving better results in speech perception and develop- mance of HI children with that of hearing children. Their re-
ment in prelingual children when compared to conventional sults revealed that both groups were found to have
hearing aids. comparable forward and backward digit span tasks suggesting
Prezbindowski and Lederberg10 and most (2012) revealed that encoding of serial information does not entail directional
that normal language development depends on intact sensory dominance. Also they found that the HI children showed bet-
channels and early hearing impairment has its impact on lan- ter auditory memory than hearing children. They suggest that
guage acquisition & competence. Also, they have pointed out memory in HI individuals who are fluent in sign language may
that early identification of hearing loss & early intervention have different characteristics than that of hearing individuals
services have a positive effect for both language and cognitive and perhaps HI individuals who rely on spoken language.
34 H.E. Hassan et al.

These diverse results may be explained by the difference in  HI and CI individuals have decreased auditory verbal-STM
the nature of the task and to-be-remembered materials during which may be due to associated language impairment.
application of different subtests. Those differences can lead to
HI individuals having equal or worse auditory memory as
compared with hearing individuals. 8. Recommendations
In the current study, the mean scores of auditory associa-
tion, auditory closure and verbal expression were better in
CI groups in comparison to HI group. Fallon et al.15 men- For HI and CI individuals, multisensory training is needed
tioned that the evoked recorded potentials of early cochlear both in therapy sessions and classrooms with more focusing
implant children suggest near-normal maturation of cortical on visual stimuli.
layers of the brain and near normal development of auditory Auditory training program should include tasks to enhance
system; moreover they have better speech perception scores and improve auditory short term memory span.
than HI children who are using hearing aids.
Aline et al.9 mentioned that, based on several studies, co-
chlear implants were demonstrated to be the best current alter-
Conflict of interest
native for bilateral severe or profound hearing loss, achieving
better results in speech perception and development in prelin-
gual children when compared to conventional hearing aids. None declared.

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