language skills in children with CIs to establish benchmarks. The second .... additional disabilities are related to language performance. As in children with ...
Predictors of Spoken Language Development Following Pediatric Cochlear Implantation 5JOOF#PPOT +BO1-#SPLY *OHFCPSH%IPPHF +PIBO).'SJKOT 5-PVJT1FFSBFS 6 "OOFLF7FSNFVMFO +BO8PVUFST 1BOE"TUSJEWBO8JFSJOHFO1 INTRODUCTION
Objectives: Although deaf children with cochlear implants (CIs) are able to develop good language skills, the large variability in outcomes remains a significant concern. The first aim of this study was to evaluate language skills in children with CIs to establish benchmarks. The second aim was to make an estimation of the optimal age at implantation to provide maximal opportunities for the child to achieve good language skills afterward. The third aim was to gain more insight into the causes of variability to set recommendations for optimizing the rehabilitation process of prelingually deaf children with CIs.
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Design: Receptive and expressive language development of 288 children who received CIs by age five was analyzed in a retrospective multicenter study. Outcome measures were language quotients (LQs) on the Reynell Developmental Language Scales and Schlichting Expressive Language Test at 1, 2, and 3 yr after implantation. Independent predictive variables were nine child-related, environmental, and auditory factors. A series of multiple regression analyses determined the amount of variance in expressive and receptive language outcomes attributable to each predictor when controlling for the other variables. Results: Simple linear regressions with age at first fitting and independent samples t tests demonstrated that children implanted before the age of two performed significantly better on all tests than children who were implanted at an older age. The mean LQ was 0.78 with an SD of 0.18. A child with an LQ lower than 0.60 (= 0.78−0.18) within 3 yr after implantation was labeled as a weak performer compared with other deaf children implanted before the age of two. Contralateral stimulation with a second CI or a hearing aid and the absence of additional disabilities were related to better language outcomes. The effect of environmental factors, comprising multilingualism, parental involvement, and communication mode increased over time. Three years after implantation, the total multiple regression model accounted for 52% of the variance in receptive language scores and 58% of the variance in expressive language scores. Conclusions: On the basis of language test scores of this large group of children, an LQ of 0.60 or lower was considered a risk criterion for problematic language development compared with other deaf children using CIs. Children attaining LQs below 0.60 should be monitored more closely and perhaps their rehabilitation programs should be reconsidered. Improved language outcomes were related to implantation under the age of two, contralateral stimulation, monolingualism, sufficient involvement of the parents, and oral communication by the parents. The presence of an additional learning disability had a negative influence on language development. Understanding these causes of variation can help clinicians and parents to create the best possible circumstances for children with CIs to acquire language. &BS)FBSJOH 99 o
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Number of children tested per evaluation period Test
1 yr after CI (n)
Number of children tested with... Only RDLS Only SELT-word Only SELT-sentence RDLS and SELT-word RDLS and SELT-sentence SELT-word and SELT-sentence RDLS and SELT-word and SELT-sentence Total number of children tested with... RDLS SELT-word SELT-sentence
2 yr after CI (n)
3 yr after CI (n)
39 1 1 26 8 3 67
18 1 0 13 11 3 117
7 1 0 10 12 2 125
140 97 79
159 134 131
154 138 139
RDLS, Reynell Developmental Language Scales; SELT-word, Schlichting Expressive Language Test—word development; SELT-sentence, Schlichting Expressive Language Test—sentence development; CI, cochlear implant.
QFSJPET XFSF OPSNBMMZ EJTUSJCVUFE ,PMNPHPSPW4NJSOPW p > -JOFBSBOEOPOMJOFBSSFHSFTTJPOTXFSFVTFEUPBTTFTTUIF SFMBUJPOTIJQCFUXFFOBHFBUmSTUmUUJOHBOEMBOHVBHFPVUDPNFT #FDBVTFOPOMJOFBSmUTEJEOPUTJHOJmDBOUMZEJGGFSGSPNMJOFBSmUT SFTVMUTXFSFEFTDSJCFECZNFBOTPGBMJOFBSBQQSPBDI.VMUJQMF MJOFBS SFHSFTTJPO NPEFMT XJUI TUFQXJTF CBDLXBSE FMJNJOBUJPO XFSFDPOTUSVDUFEUPBOBMZ[FJOEFQFOEFOUGBDUPSTSFMBUFEUPMBOHVBHFTLJMMTXIFOBEKVTUJOHGPSQPUFOUJBMDPOGPVOEFST7BSJBCMFT XIJDIXFSFOPUTJHOJmDBOUMZBTTPDJBUFEXJUIMBOHVBHF BUUIFp MFWFM XFSFFYDMVEFEGSPNUIFNPEFMT7BSJBCMFTXIJDI XFSF TJHOJmDBOUMZ BTTPDJBUFE XJUI MBOHVBHF XFSF BOBMZ[FE JO UFSNTPGUIFBNPVOUPGBEEFEWBSJBODFUIFZBDDPVOUFEGPS R2 .FBOEJGGFSFODFTJO-2TXFSFOPUFEBT$-2"MMBOBMZTFTXFSF QFSGPSNFEVTJOH4144
RESULTS 'JSTU BOPWFSWJFXPGUIFQSFEJDUJOHGBDUPSTVTFEJOUIJTTUVEZ JT HJWFO UP JMMVTUSBUF TQFDJmD DIBSBDUFSJTUJDT PG UIF QBSUJDJQBUJOHHSPVQ TFF5BCMF BOE 4FDPOE HSPVQSFTVMUTPGBMM QBSUJDJQBOUT BSF EFTDSJCFE UP QSPWJEF TPNF JOTJHIU JOUP XIBU DBOCFFYQFDUFE5IJSE UIFJOnVFODFPGBHFBUJNQMBOUBUJPOPO MBOHVBHFEFWFMPQNFOUJTFWBMVBUFE-BTU QSFEJDUJWFGBDUPSTBSF BOBMZ[FEJONVMUJQMFSFHSFTTJPONPEFMTUPFYQMBJOUIFWBSJBCJMJUZ JOMBOHVBHFPVUDPNFT
Characteristics of the Participating Children $IJME3FMBUFE 'BDUPST t 5BCMF QSPWJEFT BO PWFSWJFX PG DIBSBDUFSJTUJDTPGUIFQBSUJDJQBUJOHDIJMESFO0GQBSUJDJQBOUT XFSFCPZTBOEXFSFHJSMT"UUIFUJNFPGUFTUJOH UIFJS BHF SBOHFE GSPN UP ZS *O PG UIF DBTFT UIF DBVTFPGEFBGOFTTDPVMEOPUCFSFUSJFWFE"HFOFUJDEFWJBUJPO XJUIPVUDPOOFYJONVUBUJPODBVTFEEFBGOFTTJOPGUIF DIJMESFO XIFSFBTDPOOFYJONVUBUJPOPDDVSSFEJO5IJSUZ QFSDFOUPGUIFQBSUJDJQBOUTTVGGFSFEGSPNBOJOGFDUJPO FH $.7 NFOJOHJUJT SFTVMUJOHJOEFBGOFTT4FWFOQFSDFOUIBE B DPOHFOJUBM NBMGPSNBUJPO PG UIF DPDIMFBF FH FOMBSHFE WFTUJCVMBSBRVFEVDU BOEBNJOPSJUZPGUIFHSPVQ XBT CPSO QSFNBUVSFMZ BT B SFTVMU PG XIJDI UIFJS IFBSJOH XBT TFWFSFMZ JNQBJSFE 0G UIF DIJMESFO IBE POF PS NPSF EJTBCJMJUJFTPOUPQPGUIFJSIFBSJOHJNQBJSNFOU"NPUPSPS
CBMBODFEJTPSEFSXBTEJBHOPTFEJOPGUIFQBSUJDJQBOUT #FIBWJPSBM QSPCMFNT FH BUUFOUJPO EFmDJU IZQFSBDUJWJUZ EJTPSEFS BVUJTN TQFDUSVN EJTPSEFS PDDVSSFE JO PG UIF DBTFT 5XFOUZ DIJMESFO FYQFSJFODFE MFBSOJOH EJGmDVMUJFT FH EZTMFYJB BOE FJHIU IBE NVMUJQMF IBOEJDBQT EFTQJUF OPSNBM JOUFMMJHFODF 'JWF QBSUJDJQBOUT TVGGFSFEGSPNBVEJUPSZOFVSPQBUIZ "VEJUPSZ'BDUPSTt(FOFSBMOFPOBUBMIFBSJOHTDSFFOJOHIBT CFFOJOQMBDFJO'MBOEFSTTJODFBOEJOUIF/FUIFSMBOET TJODF 0MEFS DIJMESFO JO UIJT TUVEZ XFSF CPSO CFGPSF OFPOBUBMTDSFFOJOH(n = BOEXFSFPGUFOEJBHOPTFEBUB MBUFSBHF5IFNFBOBHFBUEJBHOPTJTXBTNP 4% NP 5IFmSTUmUUJOHPGUIF$*UPPLQMBDFBUBNFBOBHFPGZSNP 4% ZSNP XJUIUIFZPVOHFTUDIJMECFJOHNPBOEUIF PMEFTUZS&JHIUZTFWFOQFSDFOUPGUIFDIJMESFODPNQMFUFE B IFBSJOH BJE USJBM CFGPSF DPDIMFBS JNQMBOUBUJPO 5IJSUZ FJHIU DIJMESFO NPTU PG UIFN EFBGFOFE UISPVHI NFOJOHJUJT JNNFEJBUFMZSFDFJWFEB$*XJUIPVUIFBSJOHBJEFYQFSJFODF 5IF OVNCFS PG DIJMESFO XJUI CJMBUFSBM TUJNVMBUJPO WBSJFE EVSJOHUIFZSGPMMPXVQ5BCMFDPNQJMFTBMMJOGPSNBUJPO PODPOUSBMBUFSBMTUJNVMBUJPOXJUIJOUIFOJOFEBUBHSPVQT &OWJSPONFOUBM 'BDUPST t 0G UIF QBSUJDJQBOUT XFSF SBJTFEJOBNVMUJMJOHVBMFOWJSPONFOUXJUIQBSFOUTTQFBLJOH BOPUIFS MBOHVBHF FH 'SFODI "SBCJD XJUI UIF DIJME 0G UIF QBSFOUT EJE OPU VTF TJHOT JO UIF DPNNVOJDBUJPO XJUIUIFJSDIJME iPSBMw 5IFNBKPSJUZPGUIFQBSFOUT VTFETJHOTUPTVQQPSUUIFJSTQPLFOMBOHVBHF iUPUBMw 0OMZ PGUIFQBSFOUTGVMMZNBTUFSFETJHOMBOHVBHFBOESBJTFE UIFJS DIJME CJMJOHVBMMZ XJUI TQPLFO %VUDI BOE %VUDI TJHO MBOHVBHF iCJMJOHVBMw .PTU QBSFOUT XFSF TVGmDJFOUMZ JOWPMWFE
CVUJOPGUIFDIJMESFOTmMFT QSPCMFNT XFSFNFOUJPOFEXJUIQBSFOUTCFJOHJOTVGmDJFOUMZJOWPMWFEJO UIFSFIBCJMJUBUJPOQSPDFTT5IFGPVSUIFOWJSPONFOUBMGBDUPS FEVDBUJPOBM TFUUJOH WBSJFE BT B SFTVMU PG DIJMESFO NPWJOH GSPNBTQFDJBMTDIPPMUPBSFHVMBSTDIPPMPSWJDFWFSTB5BCMF DPNQJMFT BMM JOGPSNBUJPO PO FEVDBUJPOBM TFUUJOH XJUIJO UIFOJOFEBUBHSPVQT0OFBOEUXPZFBSTBGUFSJNQMBOUBUJPO TPNF DIJMESFO XFSF TUJMM UPP ZPVOH UP BUUFOE TDIPPM5IFZ XFSFDBQUVSFEVOEFSUIFMBCFMiOPTDIPPMw
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TABLE 2. Overview and main features of child-related, auditory, and environmental factors Child-related factors Gender Etiology
♂: n = 152
(52%)
Additional disabilities
Auditory factors Age at diagnosis Age at first CI fitting Hearing aid pre-CI Bilateral stimulation Environmental factors Multilingualism Communication modus
– X = 9 mo – X = 2 yr 2 mo Yes: n = 250 See Table 3 Yes: n = 49 Oral: Total: Bilingual: Sufficient: Insufficient: See Table 4
Parental involvement Educational setting
♀: n = 136 n = 56 n = 13 n = 86 n = 21 n = 12 n = 100 n = 16 n = 15 n = 20 n=8 n=5 n = 224
(47%) (19%) (5%) (30%) (7%) (4%) (35%) (6%) (5%) (7%) (3%) (2%) (77%)
SD = 8m SD = 1 yr 1 mo (87%)
No: n = 38
(13%)
(17%) n = 102 n = 166 n = 20 n = 277 n = 11
No: n = 239 (35%) (58%) (7%) (96%) (4%)
(83%)
Genetic (no connexin): Connexin mutation: Infection: Congenital malformation: Prematurity: Unknown: Motor/balance disorder: Behavioral problems: Learning disorder: Multiple handicaps: Auditory neuropathy: No additional disabilities:
– X, mean; CI, cochlear implant.
Language Levels and Risk Criterion for Problematic Language Development
'JHVSF " JMMVTUSBUFT UIF SFTVMUT SFQSFTFOUFE BT -2T PG UIF FOUJSF HSPVQ PG QBSUJDJQBOUT PO UIF 4&-5 BOE 3%-4 BOEZSBGUFSJNQMBOUBUJPO*UJTJOUFSFTUJOHUIBUUIFNFBO-2T EJEOPUDIBOHFEVSJOHUIFmSTUZSBGUFSDPDIMFBSJNQMBOUBUJPO TABLE 3. Occurrence of contralateral stimulation at each evaluation period 1 yr after CI Test RDLS CI–/ CI–HA CI–CI Total SELT-W CI–/ CI–HA CI–CI Total SELT-S CI–/ CI–HA CI–CI Total
n
%
2 yr after CI
3 yr after CI
n
%
n
%
63 62 15 140
45 44 11
85 45 29 159
54 28 18
84 41 29 154
54 27 19
37 52 8 97
38 54 8
65 42 27 134
49 31 20
73 38 27 138
53 27 20
30 42 7 79
38 53 9
61 43 27 131
46 33 21
75 39 25 139
54 28 18
RDLS, Reynell Developmental Language Scales; SELT-W, Schlichting Expressive Language Test—word development; SELT-S, Schlichting Expressive Language Test—sentence development; CI, cochlear implant.
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PUIFST BQQSPYJNBUFMZ GBJMFEUPEFWFMPQBMBOHVBHFMFWFM DPNQBSBCMFXJUIIBMGPGUIFJSDISPOPMPHJDBMBHF -2
Age at Implantation
"TFYQFDUFE BMJOFBSSFHSFTTJPOBOBMZTJTDPOmSNFEUIBUBHF BUmSTUmUUJOHPGUIF$*XBTBTJHOJmDBOUQSFEJDUPSPGMBOHVBHF TLJMMTEVSJOHUIFmSTUZSBGUFSJNQMBOUBUJPO p
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TABLE 4. Distribution between educational settings at each evaluation period 1 yr after CI Test
n
RDLS Regular Special No school Total SELT-W Regular Special No school Total SELT-S Regular Special No school Total
%
2 yr after CI
3 yr after CI
n
%
n
%
6 79 55 140
4 57 39
30 115 15 159
19 72 9
43 111 0 154
28 72 0
6 57 34 97
6 59 35
23 101 10 134
17 75 8
36 102 0 138
26 74 0
4 47 28 79
5 60 35
29 93 9 131
22 71 7
39 100 0 139
28 72 0
RDLS, Reynell Developmental Language Scales; SELT-W, Schlichting Expressive Language Test—word development; SELT-S, Schlichting Expressive Language Test—sentence development; CI, cochlear implant..
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QBSFEXJUIBOPSNNFBO"SPVOEPGUIFOPSNQPQVMBUJPO TDPSFTMPXFSUIBO4%T$POTFRVFOUMZ UIFSFTVMUTPGUIFTFDIJMESFO BSF MBCFMFE iWFSZ QPPSw &BSMZ DPDIMFBS JNQMBOUBUJPO BJNT BUNBYJNBMMZSFEVDJOHUIFOVNCFSPGDIJMESFOQFSGPSNJOHBUUIJT QPPSMFWFM(JWFOUIF4%TDVUPGGQPJOU UIFMJOFBSSFHSFTTJPO MJOFJOUFSDFQUFEBUBQQSPYJNBUFMZZS 'JHVSF .PSFPWFS JOEFQFOEFOUTBNQMFTtUFTUTDPOmSNFEUIBUDIJMESFOJNQMBOUFECFGPSF UIF BHF PG UXP QFSGPSNFE TJHOJmDBOUMZ CFUUFS PO BMM UISFF UFTUT UIBODIJMESFOXIPXFSFJNQMBOUFEBUBOPMEFSBHF p 5IFNFBOMBOHVBHFTDPSFTPGDIJMESFOJNQMBOUFEBUBZPVOHBHF ZS WBSJFECFUXFFO 4% BOE 4% 5IF SFTVMUT PG DIJMESFO JNQMBOUFE VOEFS UIF BHF PG UXP BSF DBQUVSFEJO'JHVSF#5IFNFBO-2BWFSBHFEPWFSBMMNFBTVSJOH NPNFOUTXBTBOEUIFNFBO4%XBT0VSBOBMZTFTTIPX UIBUBDIJMEXJUIBO-2MPXFSUIBO o XJUIJOZS QPTU$*JTBXFBLQFSGPSNFSDPNQBSFEXJUIPUIFSEFBGDIJMESFO JNQMBOUFEBUBZPVOHBHF"DIJMEXJUIBO-2IJHIFSUIBO
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Fig. 1. Language quotients of the RDLS and SELT 1, 2, and 3 yr after implantation. RDLS, Reynell Developmental Language Scales; SELT-W, Schlichting Expressive Language Test—word development; SELT-S, Schlichting Expressive Language Test—Sentence development. The box plots represent the smallest observation, lower quartile, median (bold line), mean (x), upper quartile, largest observation, and outliers (>1.5× interquartile range) (w).
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Fig. 2 Language quotients as a function of age at first fitting of CI. LQ, language quotient; RDLS, Reynell Developmental Language Scales; SELT-W, Schlichting Expressive Language Test—word development; SELT-S, Schlichting Expressive Language Test—sentence development. Each dot represents a participant, and the black line represents the linear regression line.
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Predictors #FTJEFTBHFBUmSTUmUUJOH FJHIUBEEJUJPOBMQSFEJDUPSTXFSF UBLFOJOUPBDDPVOUJOBNVMUJQMFMJOFBSSFHSFTTJPONPEFMHFOEFS FUJPMPHZ BEEJUJPOBMEJTBCJMJUJFT DPOUSBMBUFSBMTUJNVMBUJPO IFBSJOHBJEVTFCFGPSF$* NVMUJMJOHVBMJTN DPNNVOJDBUJPONPEF BOEQBSFOUBMJOWPMWFNFOU#FDBVTFBHFBUEJBHOPTJTDPSSFMBUFE XJUI BHF BU mSTU mUUJOH r p
JU XBT FYDMVEFE GSPN UIF NPEFM PXJOH UP NVMUJDPMMJOFBSJUZ QSPCMFNT *O BEEJUJPO FEVDBUJPOBMTFUUJOHXBTOPUJODMVEFECFDBVTFTDIPPMUZQF XBTPGUFODIPTFOPOUIFCBTJTPGMBOHVBHFPVUDPNFTBOEUIFSFGPSFDPVMEOPUCFJODPSQPSBUFEBTBOJOEFQFOEFOUWBSJBCMF
3FDFQUJWF -BOHVBHF t *O BEEJUJPO UP BHF BU mSTU mUUJOH UIFNPEFMSFWFBMFEUISFFQSFEJDUJWFGBDUPSTXJUISFTQFDUUP SFDFQUJWF MBOHVBHF ZS QPTU$* DPOUSBMBUFSBM TUJNVMBUJPO BEEJUJPOBMEJTBCJMJUJFT BOEPSBMNVMUJMJOHVBMJTN TFF5BCMF 1PTU IPD BOBMZTJT XJUI #POGFSSPOJ DPSSFDUJPO TIPXFE UIBU DIJMESFO XJUI CJMBUFSBM $*T NFBO EJGGFSFODF JO -2 p < BOEDIJMESFOXJUIBDPOUSBMBUFSBMIFBSJOH BJE NFBOEJGGFSFODFJO-2 p = QFSGPSNFE TJHOJmDBOUMZ CFUUFS PO UIF SFDFQUJWF MBOHVBHF UFTU UIBO DIJMESFOXJUIPOMZPOF$*.PSFPWFS DIJMESFOXJUIBMFBSOJOH EJTBCJMJUZIBETJHOJmDBOUMZMPXFSTDPSFTUIBODIJMESFOXJUI BNPUPSPSCBMBODFEJTPSEFS NFBOEJGGFSFODFJO-2 p = PS DIJMESFO XJUIPVU BO BEEJUJPOBM EJTBCJMJUZ NFBO EJGGFSFODF JO -2 p = -BTU PSBM NVMUJMJOHVBMJTNIBEBTJHOJmDBOUOFHBUJWFJOnVFODFPOUIF SFDFQUJWFMBOHVBHFLOPXMFEHFZSBGUFSJNQMBOUBUJPO NFBO EJGGFSFODF JO -2 p = 5IF DPNCJOBUJPO PG UIFTF GPVS QSFEJDUPST BDDPVOUFE GPS PG UIF WBSJBCJMJUZ JO SFDFQUJWF MBOHVBHF TDPSFT )FODF UIF UISFF BEEJUJPOBM GBDUPSTBDDPVOUFEGPSBEEFEWBSJBCJMJUZ 5XPZFBSTBGUFSJNQMBOUBUJPO UIFBOBMZTFTSFWFBMFEUIFTBNF GPVSQSFEJDUJWFGBDUPSTBTZSBGUFSJNQMBOUBUJPO TFF5BCMF 1PTUIPDBOBMZTFTXJUI#POGFSSPOJDPSSFDUJPOTIPXFEUIBUDIJMESFO XJUI CJMBUFSBM $*T QFSGPSNFE TJHOJmDBOUMZ CFUUFS PO UIF
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#00/4&5"-&"3)&"3*/( 70-99 /099 99o99
8
TABLE 5. Linear regression with age at first fitting RDLS R Total group—CI < 5 yr (n = 288) 1 yr after CI 2 yr after CI 3 yr after CI Early implantation—CI < 2 yr (n = 149) 1 yr after CI 2 yr after CI 3 yr after CI Late implantation—CI > 2 yr (n = 139) 1 yr after CI 2 yr after CI 3 yr after CI
2
SELT-W
p
n
2
R
SELT-S
p
n
2
R
p
n
0.261 0.322 0.322
