International Journal of Pediatric Otorhinolaryngology 75 (2011) 1327–1332

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International Journal of Pediatric Otorhinolaryngology

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The Hebrew and the Arabic version of the LittlEARS1 Auditory Questionnaire for
the assessment of auditory development: Results in normal hearing children and
children with cochlear implants
M. Geal-Dor a,b,*, R. Jbarah a,b, S. Meilijson b, C. Adelman a,b, H. Levi a,b
a
Speech and Hearing Clinic, Hadassah University Medical Center, Jerusalem, Israel
b
Department of Communication Disorders, Hadassah Academic College, Jerusalem, Israel

A R T I C L E I N F O A B S T R A C T

Article history: Objective: With more children receiving cochlear implants at an early age, there is a need for evaluation
Received 2 June 2011 and assessment of early auditory behavior. We present the translation of the LittlEARS1 Auditory
Received in revised form 25 July 2011 Questionnaire into Hebrew and into Arabic. First the validation of the LittlEARS1 Auditory Questionnaire
Accepted 27 July 2011
in normal hearing children was evaluated. Second, the auditory behavior and the progress in hearing
skills of a group of children with cochlear implants were assessed.
Keywords: Methods: A ‘‘back-translation’’ method was used to translate and adapt the LittlEARS1 Auditory
LittlEARS1 Auditory Questionnaire
Questionnaire into Hebrew and into Arabic. Normal hearing participants included 70 Hebrew speaking
Hearing loss
and 97 Arabic speaking parents of children from 1 to 24 months of age with normal hearing. An
Cochlear implant
Auditory development additional group of 42 parents of children with cochlear implants with a hearing age of up to 24 months
completed the LittlEARS1 Auditory Questionnaire. 27 of them completed the questionnaire more than
once at intervals, so that change and development could be recorded. Scores on the LittlEARS1 Auditory
Questionnaire were compared to results of SIR and CAP scales and other available auditory data.
Results: The results of the first study show that the curves found for the Hebrew and the Arabic
translations of the LittlEARS1 Auditory Questionnaire are essentially similar to those previously found
for other languages. These curves reflect the age dependency of auditory skills. Furthermore, in the group
with cochlear implants the developmental pattern was different than that of the normal hearing group,
with an initial steep increase and a later slower improvement. This trend appeared both in curves of
groups and in curves of individuals (individuals whose parents completed the questionnaire at several
points in time). There was a high correlation between scores on the LittlEARS1 Auditory Questionnaire
and results of other audiologic tests, showing validity of results with the LittlEARS1 Auditory
Questionnaire.
Conclusion: Both the Hebrew and Arabic versions of the LittlEARS1 Auditory Questionnaire were found
to be reliable and valid tools for assessment of the development of auditory behavior in children up to the
age of 24 months. Furthermore, the LittlEARS1 Auditory Questionnaire in both languages is useful in
monitoring the progress of children with cochlear implant.
ß 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Cochlear implantation is an effective treatment for severe to
profound hearing loss. Nowadays children are implanted as early
as 12 months of age (and even earlier). It is very important to
evaluate and monitor their progress with the cochlear implant, as
hearing at this very young age is critical for the development of
speech and language [e.g. [1,2]].
* Corresponding author at: Speech and Hearing Clinic, Hadassah University
Medical Center, Jerusalem, Israel. Tel.: +972 2 9919075.
E-mail address: miriam112@bezeqint.net (M. Geal-Dor).
Over the years many tools have been developed to assess
development and progress, but most tools are inadequate at this
very young age. Use of parental questionnaires to evaluate young
children’s behavior has many advantages as a supportive tool in
the evaluation of young children. Parental observation is particu-
larly important when children are uncooperative in an unfamiliar
environment or are too young to participate in standardized
speech perception tests. Furthermore, this early pre-verbal
auditory behavior cannot always be seen in the clinic while it is
observed in natural situations and parents can easily describe their
child’s responses. Parent questionnaires are a well established
technique and have been used in many behavioral, emotional, and
language evaluations and been found to be suitable and reliable
screening tools with high validity [e.g. [3–5]].

0165-5876/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2011.07.030
1328 M. Geal-Dor et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1327–1332
One such questionnaire is the LittlEARS1 Auditory Question-
naire which was developed by Coninx et al. [6]. The questionnaire
is part of a battery of tests, Evaluation of Auditory Responses to
Speech (EARS) [7]. LittlEARS1 Auditory Questionnaire is specifi-
cally developed for children under 2 years of age. The question-
naire is based on the developmental research of auditory behavior
milestones which exist in the repertoire of very young children at
the preverbal stage. The questionnaire was validated in 15
different languages for normal hearing infants and toddlers and
found to be quick and easy to administer [8].
Currently there are very few suitable questionnaires in either
Hebrew or Arabic. The purpose of this study was to assess the
adequacy of a Hebrew and an Arabic translation of the LittleEARS
questionnaire on a group with normal hearing, and then to use the
LittlEARS1 Auditory Questionnaire to evaluate the development
and progress of auditory behavior in a group of cochlear implanted
children over time.
2. Methods
2.1. Subjects
2.1.1. Normal hearing children
The LittlEARS1 Auditory Questionnaire was filled out by 70
Hebrew speaking and 97 Arabic speaking parents of children (79
males, 88 females) in the age range of 1–24 months, with an
average age of 13 months (SD = 7). The Arabic speaking parents
were from four different areas in Israel with slightly different
dialects: the northern parts (n = 29), two central areas [the Triangle
villages (n = 12) and Jerusalem (n = 31)] and the southern part
(including the Bedouin) of the country (n = 25). We made an effort
to distribute the questionnaire to the Arabic speaking parents in
the various geographic regions so as to be sure it was understood
by speakers of all the different dialects. Parents were volunteers
recruited through friends, or during a visit to a nursery school. All
parents completed the questionnaire independently. We report
here only on those 167 parents whose children were suitable for
this study, as parents first filled out a short survey and were
excluded if they reported on the survey that their child had a
history of: hearing loss, aural disease, neurologic or other
developmental disorder.
2.1.2. Cochlear implant group
The subjects were 20 Hebrew speaking and 22 Arabic speaking
parents of children with a cochlear implant (25 males, 17 females).
The average chronological age was 39 months (SD = 11, range 15–
69 months). The average age of implantation was 29 months
(SD = 10, range 12–57 months). Eleven were implanted with the
Nucleus 24 Contour, 24 were implanted with the Nucleus Freedom,
and 7 with the Advanced Bionics 90k. The average hearing age, i.e.
months since implantation, was 9 months (SD = 6, range 1–23
months). Parents were excluded if they reported on the initial
survey that their child was known to have additional disabilities.
Parents were asked to complete the questionnaire during their
routine visit to the Hadassah University Medical Center Audiology
Clinic for a mapping session. Out of the 42 children with a cochlear
implant, 39 were monaurally implanted and 3 were sequentially
binaurally implanted.
To measure individual development, 27 of these parents were
asked to complete the questionnaire a second time an average of 8
months after the first time (SD = 5 months), and a subgroup of 12
parents completed the questionnaire a third time at an average
interval of 6 months after the second time (SD = 3 months).
The study was approved by the Hadassah University Medical
Center Ethics Committee.
2.2. Materials
The LittlEARS1 Auditory Questionnaire is comprised of 35 ‘‘yes/
no’’ questions designed to test the observed receptive, semantic
and early expressive language skills of very young children in
response to auditory input. Most of the items are supplemented
with examples to make the questions more precise. Two examples
of questions: ‘Is your child interested in toys producing sounds or
music? e.g. rattle, squeezing toy’ or ‘Does your child try to sing
along when hearing a song? e.g. nursery rhymes’. Each subject was
instructed to respond with a ‘‘yes’’ to a question if she or he had
observed the behavior in their child at least once, and to respond
with a ‘‘no’’ if she/he had never observed the behavior or if she/he
was not sure how to answer the question. Parents of normal
hearing children were instructed to discontinue completion of the
questionnaire after six successive ‘‘no’’ answers. In such a case, the
remaining answers were assumed to be ‘‘no‘‘. Parents of children
with a cochlear implant were instructed to complete the
questionnaire regardless of the answers as the developmental
order may not be the same as in children with normal hearing. The
total score of the questionnaire for each subject was the sum of all
‘‘yes’’ answers.
The English version of the LittlEARS1 Auditory Questionnaire
was provided by the MED-EL Corporation, and translated into
Hebrew and into Arabic by the authors. A ‘‘back-translation’’
method was used to assure identical or highly similar meanings
between the original and translated versions, and in order to
overcome cultural differences between languages as well as
subtle differences in meaning due to the fact that some words or
expressions have no direct equivalents in another language. The
‘‘back-translation’’ method includes translation from the original
language into the target language, then a ‘‘back-translation’’ from
the target language to the original language and finally compari-
son of the back-translation with the original version according to
the guidelines recommended by Guillemin et al. [9]. Obrycka et al.
[10] have shown the use of ‘‘back-translation’’ method for the
adaptation of the LittlEARS1 Auditory Questionnaire in Polish. An
outside reader–speech therapist experienced and fluent in both
languages provided feedback on the translation, which resulted in
some minor modifications, mainly of the examples chosen.
Furthermore, an expert in the Arabic language in Israel read the
Arabic translation and suggested the necessary adjustments so
that it would be understood by speakers of all the different
dialects.
In order to evaluate the accuracy of the LittlEARS1 Auditory
Questionnaire, the score was compared to scores on the Category
of Auditory Performance (CAP) and Speech Intelligibility Rating
(SIR), both scales which are used routinely in the clinic [11,12].
The LittlEARS1 Auditory Questionnaire score was also com-
pared to audiometric data available. Two scales were constructed.
In the domain of speech threshold scale, if the child was capable of
speech detection threshold (SDT) only, he scored 1, but if he was
capable of closed set speech reception threshold (SRT) he scored 2.
Similarly the speech perception scale included a score of 1 if the
child was at the stage of detection of Ling sounds, a score of 2 if he
was able to discriminate and repeat all Ling sounds, and a score of 3
if he was able to repeat VCV sounds.
2.3. Data analyses
Statistical analysis included correlation tests for simple
correlations. t-Tests were used to compare between languages
and sex. ANOVA was used to examine changes over time. Level of
significance was set to 0.05. Total score on the LittlEARS1 Auditory
Questionnaire was correlated with age, as well as scores on other
tests such as SIR, CAP and audiometric data.
 M. Geal-Dor et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1327–1332
3. Results
3.1. Children with normal hearing
The correlations between total LittlEARS1 scores (i.e. the
number of ‘yes’ answers) and age can be seen as a measure of a
child’s age-appropriate auditory behavior. The correlation was
measured between LittlEARS1 total score and age and was found
to be significant both for Hebrew (r = 0.91) and for Arabic (r = 0.84).
A high correlation was found between question’s serial number
and the number of parents that answered ‘‘yes’’ on that question
(Hebrew r = 0.94; Arabic r = 0.93) showing that the questions
are indeed set in an increasing order of difficulty. The validity and
reliability of the translated versions of the LittlEARS1 question-
naire were tested and had a good reliability with high internal
consistency (Cronbach’s a: 0.961 for Hebrew and 0.950 for Arabic;
Guttman’s split-half-coefficient: 0.796 for Hebrew and 0.651 for
Arabic).
t-Test did not reveal a significant difference in the scores
between the Hebrew and the Arabic speaking parents (p = 0.18). An
ANOVA to compare the scores of speakers of the 4 different Arabic
dialects was also not significant (p = 0.95). In addition, gender
effect (male/female) was not significant (p = 0.29).
The seventy Hebrew speaking parents filled out the CAP and SIR
scales in addition to the LittlEARS1 Auditory Questionnaire. A high
correlation was found between the LittlEARS1 score and the CAP
(r = 0.78) as well as the SIR (r = 0.72).
Curves were generated for Hebrew and Arabic normal hearing
children. Regression equations were used to calculate the norm
curves (see Fig. 1). The best model, explaining 85.7% (Hebrew), and
72.7% (Arabic), respectively, of the total variance was a second
order polynomial regression with the regression equation:
OVERALL 15 languages from Coninx et al:½6
y ¼ 3:470 þ 2:163x  0:038  2
Hebrew y ¼ 2:531 þ 2:181x  0:036  2
Arabic y ¼ 4:744 þ 1:862x  0:029  2
where x is age and y = total score (ANOVA, Hebrew: F(67) = 200.67,
p < 0.001; Arabic: F(94) = 125.41, p < 0.001).
Fig. 1. LittlEARS1 validation data of normal hearing (NH) children. Regression curves (quadratic) with age as independent variable and total score as dependent variable.
Standardized expected values (norm curve) of age-specific auditory behavior for the OVERALL sample (see Coninx et al. [6]) (triangles) and for Hebrew (grey line) and Arabic
(black line). Also seen are individual values for Hebrew (n = 70) and Arabic (n = 97).
1329
To compare across languages and countries, the Hebrew and the
Arabic curves were correlated with the original German and
Austrian sample and the OVERALL sample of 15 languages [8].
Pearson’s correlation coefficients were very high (between
r = 0.999 and r = 1.000) and very significant (p < 0.001). This
implies very good comparability of all language-specific norm
data, i.e. the German and Austrian curve and the OVERALL norm
curve with the Hebrew and Arabic.
3.2. Children with cochlear implants
The correlations between total LittlEARS1 scores and age in the
cochlear implanted group were calculated for chronological age,
hearing age, and age at implantation. The correlation was found to
be significant for hearing age only (r = 0.53) and non-significant for
chronological age (r = 0.34) and for age at implantation (r = 0.03).
There were results of CAP and SIR from 13 children. LittlEARS1
score was correlated with results from CAP (r = 0.73) as well as SIR
(r = 0.56) scales. There were results from speech threshold testing
in 35 cases, and speech perception level in 18. LittlEARS1 total
score was also correlated with audiometric data such as mode of
speech threshold (SDT vs SRT) (r = 0.45) and speech perception
level tested using Ling sounds and VCV testing (r = 0.58).
Comparison of the Hebrew and the Arabic data of children with
cochlear implant to the OVERALL norm curve of normal hearing
children [6] is presented in Fig. 2. The outcomes demonstrate that
in the early stage of the first 10 months after implantation the
children showed higher performance of auditory skills compared
to their hearing age, and at a later stage the progress in auditory
skills was more similar to their hearing age, until they reached a
plateau around the age of 20 months post implantation.
Performance of 27 children with cochlear implants was
evaluated using the LittlEARS1 Auditory Questionnaire over time.
Those cochlear implanted children with more than one point in
time are presented in Figs. 3 and 4 compared to the norm curve of
OVERALL normal hearing children. At the second point in time, six
cochlear implanted children had a hearing age higher than 24
months. Therefore these values were replaced by 24 so that it
would be possible to see the change over time and to compare the
individual values with the norm curve of the OVERALL normal
hearing children.
For the Hebrew speaking group, repeated measure ANOVA
revealed a significant effect of time (i.e. test intervals) on total
scoring over time (n = 8; F(1.09,7.62) = 9.468, p = 0.015). The
pairwise comparisons (Bonferroni adjusted) showed a significant
1330 M. Geal-Dor et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1327–1332

Fig. 2. LittlEARS1 standardized expected values (norm curve) of age-specific auditory behavior for the OVERALL sample (Coninx et al. [8]) (triangles) and a trendline
(polynomic) of age-specific auditory behavior for the Hebrew (grey) and Arabic (black) cochlear implanted. Individual values of the Hebrew (n = 20) and Arabic (n = 21) CI-
children are presented versus the OVERALL sample.

difference between the first and the second test interval
(p = 0.004), and between the first and the third test interval
(p = 0.040), but not between the second and the third test interval
(p = 0.221).
The results of the repeated measure ANOVA for the Arabic
speaking group showed a tendency to significance for time (=test
intervals) on total scoring over time (n = 4; F(2,6) = 3.911,
p = 0.082). The pairwise comparisons revealed no significant
differences between the single test intervals (p = 0.396–0.736).
Age of implantation had no effect on the rate of progress: the
children implanted both earlier and later did not show a difference
in the rate of progress reflected in the t-test with no significant
change in LittlEARS1 total score between the time points
measured in the group implanted before the age of 24 months,
compared to the group implanted after the age of 24 months.
4. Discussion
The high correlation between age and LittlEARS1 score in
normal hearing children indicates that the overall responses to the
questionnaire reflect a consistent increase in auditory abilities
with maturation. Results from a number of studies [8,10] reveal
that the norm curves follow similar gradients in all languages. The
results of the present study indicate that the translation of the
LittlEARS1 Auditory Questionnaire to Hebrew and to Arabic closely
approximates the findings obtained in other languages.
The majority of cochlear implant users developed auditory
skills at a faster pace than would be expected from their hearing
age. Evidence of increased rate of development compared to
normal hearing children has been found previously [13]. It can very
well be that their older chronological age and more mature
cognitive abilities as well as the habilitation program they were
enrolled in contributed to the rapid growth and high performance
in auditory skills. May-Mederake et al. [2] demonstrated that
children implanted at a younger age (<12 months) start off on a
lower level and then develop faster and reach the highest scores
more quickly than the group implanted at an older age (>12
months). In the present study, chronological age at time of
implantation was mainly higher than 24 months and therefore
such a comparison was not possible.
Age of implantation is known to affect children’s auditory skills
as well as receptive and expressive language development over
time [14,15]. McConkey Robbins et al. [16] assessed development
of auditory skills using the IT-MAIS (Infant-Toddler Meaningful
Auditory Integration Scale) and found a rapid improvement in
auditory skills during the first year of cochlear implant use
regardless of age at implantation although younger children
achieved higher scores. However, in the present study, the

Fig. 3. LittlEARS1 data of the Hebrew cochlear implanted children (n = 16) over time (two to three test intervals) compared to the standardized expected values (norm curve)
of age-specific auditory behavior for the OVERALL normal hearing.
 M. Geal-Dor et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1327–1332
Fig. 4. LittlEARS1 data of the Arabic cochlear implanted children (n = 11) over time (two to three test intervals) compared to the standardized expected values (norm curve) of
age-specific auditory behavior for the OVERALL normal hearing.
LittlEARS1 Auditory Questionnaire results were not affected by age
at implantation. This can be explained by the fact that there were
not many early implanted children included in the present study.
However, it is possible that the finding that age of implantation did
not influence the LittlEARS1 Auditory Questionnaire score in the
present study may imply that the early preverbal stages of auditory
perception that do not involve language are achieved also in later
implanted children.
A most important outcome of the present study as well as
previous studies [2,13] is that the LittlEARS1 Auditory Question-
naire is a useful tool for assessment of cochlear implanted children
in the early stages of preverbal development. Furthermore, results
confirm that the LittlEARS1 Auditory Questionnaire is suitable for
evaluation of the development of auditory behaviors longitudinal-
ly over time in individual children. Our results showed a significant
effect of time for Hebrew speaking children and a tendency
towards time effect in Arabic speaking children. The difference
between the first and the second test interval was more
pronounced than between the second and the third test interval.
This difference may have been influenced by a ceiling effect as
some of the children achieved a very high total score already at the
beginning, and only a small number of parents filled out the third
questionnaire. Earlier studies using different parental question-
naires all reported that the largest increase and progress appeared
within the first year after implantation and more gradual progress
after that (e.g. Purdy et al. using the ABEL [17]; Sainz et al. using
EARS [18]; McConkey Robbins et al. using IT-MAIS [16]; Meinzen-
Derr et al. using the Auditory Skills Checklist, ASC [5]). This again
supports the quicker development found in the early stage
compared to later stages, confirming the high plasticity of the
brain and learning abilities found in children once they have access
to auditory stimulation.
May-Mederake et al. [2] mentioned the importance of
comparison of questionnaire data with audiometric data to prove
the criterion validity of the questionnaire. Obrycka et al. [10] also
emphasizes the importance of comparing auditory development as
indicated by the questionnaire with other measures of auditory
function. Purdy et al. [17] used the ABEL parental questionnaire
and found improvements in both speech perception and question-
naire scores over time. Meinzen-Derr et al. [5] used the Auditory
Skills Checklist (ASC). In the present study, the correlation found
for a comparison of the questionnaire score with SIR and CAP scales
as well as to available audiometric data such as mode of speech
threshold testing possible with the child (SDT vs. SRT) or speech
perception tests such as Ling sounds and VCV testing, strongly
supports the use of the LittlEARS1 Auditory Questionnaire to make
1331
informed and accurate inferences about auditory development in
infants and young children. The relatively lower correlation
between LittlEARS1 score and the audiometric data compared
to the higher correlation with SIR and CAP might reflect the fact
that the measures of mode of speech threshold and speech
perception also involve speech and language and are not auditory
per se.
In this study, there was no consideration accorded to variables
such as mode of communication (e.g. oral, signing), type of
intervention, or which parent (father, mother) replied to the
questionnaire. Variation in these factors may contribute to
differences reported in development. Furthermore, the number
of participants in this study was limited and the intervals between
the data point collection were not constant.
5. Conclusion
Both the Hebrew and Arabic versions of the LittlEARS1 Auditory
Questionnaire were found to be reliable and valid tools for
assessment of the development of auditory behavior in children up
to the age of 24 months. Furthermore, the LittlEARS1 Auditory
Questionnaire in both languages is useful in monitoring the
progress of children with cochlear implant. The LittlEARS1
Auditory Questionnaire can also be useful in providing detailed
information in multicultural areas when there is inadequate
communication between the audiologist and parent who are not
sufficiently proficient in each other’s language. LittlEARS1
Auditory Questionnaire could also be a powerful tool for
documenting a child’s own progress; it can provide evidence for
building realistic expectations, and possibly assist in planning
therapy, intervention and rehabilitation programs as well as the
need for considering refining of MAPping when progress in
auditory skills is not as expected. LittlEARS1 Auditory Question-
naire may also highlight the need for further follow-up in other
developmental areas in children with additional disabilities.
Acknowledgements
For their help with the translations, we would like to thank: Dr.
Avivit Ben David, Salwa Hneef, Khulud Amara, Ashwak Saadi and
Sophie Hassan. For their help in collection of the data, we would
like to thank: Offi Gal, Ahlam Riaty, Amal Nasser, Yael Antman,
Hanit Balori, Meital Balaish and Orit Ilani. The authors would like to
thank Dr. Jaclyn Spitzer for helpful discussions and suggestions.
We are grateful to MED-EL Medical Electronics GmbH in Innsbruck,
Austria, and especially Joanna Brachmaier and Edda Amann, for
1332 M. Geal-Dor et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1327–1332
their permission and support in the adaptation of the question-
naire to Hebrew and to Arabic as well as their help with the
statistical analysis. Thanks to the Newman fund for pediatric
audiology research.
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