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Speech Intelligibility and Psychosocial Functioning in Deaf Children and Teens with Cochlear Implants

February 2017
Journal of Deaf Studies and Deaf Education 22(3)

DOI:10.1093/deafed/enx001

Authors:

Valerie Freeman

Oklahoma State University - Stillwater

David B Pisoni

Indiana University Bloomington

William G Kronenberger

Indiana University School of Medicine

Irina Castellanos

The Ohio State University

Deaf children with cochlear implants (CIs) are at risk for psychosocial adjustment problems, possibly due to delayed speech-language skills. This study investigated associations between a core component of spoken-language ability—speech intelligibility—and the psychosocial development of prelingually deaf CI users. Audio-transcription measures of speech intelligibility and parent-reports of psychosocial behaviors were obtained for two age groups (preschool, school-age/teen). CI users in both age groups scored more poorly than typically-hearing peers on speech intelligibility and several psychosocial scales. Among preschool CI users, five scales were correlated with speech intelligibility: functional communication, attention problems, atypicality, withdrawal, and adaptability. These scales and four additional scales were correlated with speech intelligibility among school-age/teen CI users: leadership, activities of daily living, anxiety, and depression. Results suggest that speech intelligibility may be an important contributing factor underlying several domains of psychosocial functioning in children and teens with CIs, particularly involving socialization, communication, and emotional adjustment.

Correlations between BIT speech intelligibility and BASC-2 scale scores within the Study 1 preschool CI sample. BIT T1 BIT T2

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For Peer Review

Speech Intelligibility and Psychosocial Functioning in Deaf

Children and Teens with Cochlear Implants

Journal:

Journal of Deaf Studies and Deaf Education

Manuscript ID

JDSDE-16-0128.R1

Manuscript Type:

Empirical Manuscript

Keywords:

cochlear implant, social functioning, speech production

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 1

Speech Intelligibility and Psychosocial Functioning in Deaf Children and Teens with

Cochlear Implants

Abstract

Deaf children with cochlear implants (CIs) are at risk for psychosocial adjustment

problems, possibly due to delayed speech-language skills. This study investigated associations

between a core component of spoken-language ability—speech intelligibility—and the

psychosocial development of prelingually deaf CI users. Audio-transcription measures of speech

intelligibility and parent-reports of psychosocial behaviors were obtained for two age groups

(preschool, school-age/teen). CI users in both age groups scored more poorly than typically-

hearing peers on speech intelligibility and several psychosocial scales. Among preschool CI

users, five scales were correlated with speech intelligibility: functional communication, attention

problems, atypicality, withdrawal, and adaptability. These scales and four additional scales were

correlated with speech intelligibility among school-age/teen CI users: leadership, activities of

daily living, anxiety, and depression. Results suggest that speech intelligibility may be an

important contributing factor underlying several domains of psychosocial functioning in children

and teens with CIs, particularly involving socialization, communication, and emotional

adjustment.

Keywords: speech intelligibility, psychosocial behavior, cochlear implants

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 2

Speech Intelligibility and Psychosocial Functioning in Deaf Children and Teens with

Cochlear Implants

The auditory input provided by a cochlear implant (CI) dramatically improves the speech

perception and spoken language skills of prelingually deaf children, especially when

implantation occurs at an early age (e.g., Geers & Nicholas, 2013; Geers, Nicholas, & Sedey,

2003; Nicholas & Geers, 2007; Svirsky, Chin, & Jester, 2007; Svirsky, Teoh, & Neuburger,

2004). Many young children with CIs are able to perceive and produce spoken language well

enough to attend mainstream schools and interact using spoken language with hearing peers,

family, and strangers. However, even with speech and language habilitation, many young CI

users still experience delays in language development, and enormous variability in speech,

language, and literacy outcomes is routinely reported at CI centers around the world (e.g., Geers,

2002; Geers & Hayes, 2011; Ertmer, 2007; Niparko et al., 2010; Pisoni et al., 2008; Sarant,

Blamey, Dowell, Clark, & Gibson, 2001; Svirsky et al., 2007).

One important speech-language outcome measure is speech intelligibility—how well the

deaf child’s speech is recognized by others. (Note that here, intelligibility reflects on the talker’s

speech production as measured by listeners’ correct recognition of the talker’s words. This

should not be confused with another common use of the term ‘intelligibility’ as referring to the

receptive skills of the listener to recognize other’s words. In the work discussed here, talkers are

intelligible if listeners recognize their words correctly.) Good speech intelligibility is often

viewed as an important benchmark of expressive speech-language development because it

requires all core components of speech perception, cognitive processing, linguistic knowledge,

and articulation to be mastered (Chin, Bergeson, & Phan, 2012; Chin & Svirsky, 2006; Ertmer,

2011; Monsen, 1978; Montag, AuBuchon, Pisoni, & Kronenberger, 2014). Furthermore, speech

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 3

intelligibility has high face validity because it is instantly judged by any interlocutor without

reference to less apparent language components like vocabulary size, syntax, or comprehension

(Svirsky et al., 2007; Svirsky, Chin, Miyamoto, Sloan, & Caldwell, 2002). Thus, when speech

intelligibility is less than optimal, other areas of development, daily living, and social functioning

may be affected. Relations between speech intelligibility and several areas of psychosocial

adjustment in young CI users are the focus of the work presented here.

Background and Problem

Studies by Most and her colleagues have found links between speech intelligibility in

children with mild to profound hearing loss who use CIs or hearing aids and their loneliness,

sense of coherence, and social competence. Speech intelligibility also influences how peers and

teachers view the personalities, abilities, and intelligence of children with hearing loss (Most,

2007; Most, Ingber, & Heled-Ariam, 2012; Most, Weisel, & Lev-Matezky, 1996; Most, Weisel,

& Tur-Kaspa, 1999). Using teacher ratings, peer ratings, and self-reports, Most and colleagues

reported difficulties in these domains for children with hearing loss from kindergarten through

high school, with better psychosocial outcomes related to better ratings of speech intelligibility,

among other factors. Importantly, hearing peers’ attitudes about deaf children’s personal

qualities (e.g., likeability, intelligence, confidence, extroversion) were closely related to deaf

children’s speech intelligibility: as intelligibility improved, so did peers’ attitudes, particularly

those of peers with little experience with deaf speakers (Most et al., 1999). These findings

establish the importance of speech intelligibility as an integral link between linguistic and

psychosocial abilities.

Other studies have found similar links between intelligibility and psychosocial

functioning in children with hearing loss. Among children with hearing loss, those with better

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 4

speech-language skills displayed better psychosocial adjustment on a variety of related

dimensions (Dammeyer, 2010) including social competence (Hoffman, Cejas, Quittner, & The

CDaCI Investigative Team, 2016; Hoffman, Quittner, & Cejas, 2015; Kronenberger, Ditmars,

Henning, Castellanos, & Pisoni, 2016; Wiefferink, Rieffe, Ketelaar, & Frijns, 2012), social

development and self-care (Leigh et al., 2015), socialization and social integration with hearing

peers (Bat-Chava & Deignan, 2001; Bat-Chava, Martin, & Kosciw, 2005; Stinson, Whitmore, &

Kluwin, 1996), social skills and self-esteem (Moog, Geers, Gustus, & Brenner, 2011), social

adjustment, self-image, and emotional adjustment (Polat, 2002), and social functioning and

behavioral problems (Barker et al., 2009; Netten et al., 2015).

In short, if a child’s speech articulation is difficult to understand, frustrated peers may

avoid social contact, and with less social interaction, the child has fewer opportunities to learn

appropriate social behaviors. In addition, because speech communication is essential to

friendship and peer interactions, a poorly-intelligible deaf child with few friends or poor-quality

social interactions may become lonely and experience other negative emotions that may impact

both psychological development and quality of life (Batten, Oakes, & Alexander, 2014; Most,

2007; Most et al., 2012; Xie, Potměšil, & Peters, 2014). Preventing such a situation is important

for children, but standardized assessment and appropriate clinical interventions for psychosocial

functioning are not always a central component of post-implant assessment and treatment

(Hoffman et al., 2016), despite the documented prevalence of psychosocial difficulties in deaf

children with and without CIs (for reviews, see Batten et al., 2014; Moeller, 2007; Stevenson,

Kreppner, Pimperton, Worsfold, & Kennedy, 2015; Xie et al., 2014).

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 5

Rationale, Research Questions, and Hypotheses

The purpose of the two studies reported here was to investigate relations between speech

intelligibility and psychosocial-behavioral adjustment in early-implanted children and teens with

CIs. Understanding these relations is of critical importance for the treatment of children with CIs

because both speech intelligibility and psychosocial outcomes have been identified as at-risk

areas for CI users (Batten et al., 2014; Chin, Tsai, Gao, 2003; Hoffman et al., 2015; Geers &

Nicholas, 2013; Moeller, 2007; Netten et al., 2015; Stevenson et al., 2015; Svirsky, Sloan,

Caldwell, & Miyamoto, 2000; Xie et al., 2014). However, outcomes for treatment of speech

intelligibility remain highly variable, a consensus has not been reached regarding specific

psychosocial areas to target, and widespread behavioral intervention programs have yet to be

implemented with this clinical population (Batten et al., 2014; Chin et al., 2003; Dammeyer,

2010; Geers & Nicholas, 2013; Hoffman et al., 2016; Niparko et al., 2010; Peng, Spencer, &

Tomblin, 2004; Tobey, Geers, Sundarrajan, & Shin, 2011).

To help address these issues with an approach that is practical for both researchers and

clinicians, the present studies combined well-established, easily-administered, audio-

transcription measures of speech intelligibility—the Beginner’s Intelligibility Test (BIT;

Osberger, Robbins, Todd, & Riley, 1994) and McGarr Sentence Intelligibility Test (McGarr,

1981)—and parent-reported behavior problems and psychosocial adjustment—the Behavior

Assessment System for Children, Second Edition (BASC-2; Reynolds & Kamphaus, 2004).

Much of the previous work connecting these two domains has employed a variety of time- or

interpretation-intensive methods, such as parent interviews (e.g., Bat-Chava & Deignan, 2001),

holistic ratings of speech intelligibility (e.g., Dammeyer, 2010; Most et al., 1996; Most et al.,

2012), or observational evaluations of a specific set of psychosocial behaviors (e.g., Barker et al.,

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 6

2009; Quittner, Leibach, & Marciel, 2004). The behavioral tests used here are simple to

administer, score, and interpret, providing objective scores of speech intelligibility performance

and several areas of psychosocial adjustment which can be easily collected by clinicians or

researchers multiple times throughout childhood and compared between populations of different

ages. We investigated three research questions using this methodology:

Research Question 1: How does the speech intelligibility and psychosocial functioning of

early-implanted CI users compare to typically-hearing (TH) peers?

Research Question 2: What are the relations between speech intelligibility and

psychosocial outcomes in CI users?

Research Question 3: Do relations between speech intelligibility and psychosocial

outcomes in CI users hold at both early (preschool) and later (school-age and

teen) ages?

Consistent with a large body of previous research, we hypothesized lower speech

intelligibility, on average, in the CI samples compared to the TH samples (Chin et al., 2003;

Peng et al., 2004; Svirsky, Sloan, et al., 2000; Tobey et al., 2011), but we also expected a subset

of CI users to show good speech intelligibility (Ertmer, 2007; Montag et al., 2014; Osberger et

al., 1994; Tobey, Geers, Brenner, Altuna, & Gabbert, 2003). Similarly, we hypothesized poorer

psychosocial functioning, on average, in the CI samples compared to the TH samples,

particularly on scales related to social, communicative, and executive functioning, in line with

previous work which has reported more difficulties among deaf and hard-of-hearing people than

TH peers in areas such as social and communicative competence (Hoffman et al., 2015; Hoffman

et al., 2016; Xie et al., 2014), emotional regulation and behavior problems (Barker et al., 2009;

Kronenberger et al., 2016; Netten et al., 2015; Stevenson et al., 2015; Wiefferink et al., 2012),

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and attention and other executive functions (Beer et al., 2014; Castellanos, Kronenberger, &

Pisoni, 2016; Kronenberger et al., 2016; Kronenberger & Pisoni, 2014; Quittner et al., 2004).

Regarding our second research question, we hypothesized a positive correlation between speech

intelligibility and psychosocial adjustment (Barker et al., 2009; Markides, 1989; Most, 2007;

Most et al., 2012). In order to address our third research question, we report results from two

samples of CI users and TH controls: in Study 1, we examined preschoolers’ BIT and BASC-2

scores from two consecutive years, and in Study 2, we examined McGarr and BASC-2 scores

from one time point for school-age children and teens.

Study 1: Preschool Children

This study sought to uncover relations between measures of speech intelligibility and

psychosocial-behavioral development collected at two annual testing times from pre-lingually

deaf preschool children with CIs and TH controls.

Method

Participants. The children included in this study were a subset of participants involved

in a larger longitudinal investigation of linguistic, behavioral, and neurocognitive development in

preschool children with cochlear implants (Beer et al., 2014; Kronenberger & Pisoni, 2014). CI

participants were recruited from patient populations receiving services at a large university

hospital-based CI clinic and the surrounding community. Children were recruited for the TH

control sample through advertisements in the same hospital and community.

The present cochlear implant sample (CI) consisted of 27 children with CIs who fit the

following criteria: (1) severe-to-profound bilateral hearing loss (>70 dB hearing loss at 500,

1000, and 2000 Hz in the better-hearing ear) identified prior to 6 months of age; (2) CI

implantation by age 3 years; (3) age at the time of first testing between 3;0 and 6;11 years; (4)

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 8

consistent use of a multichannel CI with an up-to-date processing system ; (5) a primarily

English home environment; (6) enrollment in an aural rehabilitative program that encourages the

development of speaking and listening skills; (7) no additional developmental or cognitive

delays; (8) speech intelligibility and psychosocial behavior scores available from the first testing

session (Time 1) and/or the testing session the following year (Time 2). Of the total 27 CI users,

18 had speech intelligibility scores available from both testing times, 6 had scores from Time 1

only, and 3 had scores from Time 2 only, for a total of 24 CI users at Time 1 and 21 at Time 2.

Length of CI use at Time 1 ranged from six months to five years (M = 2.8, SD = 1.1 years).

The TH control sample consisted of 30 children with typical hearing (pure-tone average

in the normal range and no history of hearing aid use). They were also between ages 3;0 and 6;11

at time of first testing, reported no developmental or cognitive delays, resided in monolingual

English-speaking home environments, and had speech intelligibility scores available for Time 1

and/or Time 2. All 30 had speech intelligibility scores from Time 1, but only 27 had scores from

Time 2. Table 1 summarizes demographic and CI device information for the two samples with

means, standard deviations, and ranges. Demographic characteristics were comparable, with no

significant differences in mean age, nonverbal IQ, or family income between the CI and TH

samples (two-tailed Welch’s t tests, all p > .05). Nonverbal IQ was assessed by T-scores (M =

50, SD = 10) on the Differential Ability Scales II Picture Similarities subtest (Elliot, 2007); 84%

of CI users scored within one standard deviation of the age norm (i.e., scores of 40-60), and only

one scored below 40, while 37% of TH controls scored above 60 and none scored below 40.

Annual family income was coded on a 10-point scale; 38% of CI users were at the highest point

on the scale (>$95,000/year), and 33% were in the lower half of the scale (<$35,000/year), while

23% of TH controls were at the highest point and 10% in the lower half.

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[INSERT Table 1 ABOUT HERE]

Measures.

BIT. The Beginner’s Intelligibility Test (Osberger et al., 1994) is a sentence-imitation

task that was created for use with young children with hearing loss and that has been used

previously with deaf children with CIs (Castellanos et al., 2014; Chin et al., 2012; Chin et al.,

2003; Ertmer, 2007, 2011; Miyamoto et al., 1997; Osberger et al., 1994; Svirsky, Sloan et al.,

2000). The BIT consists of four lists of 10 simple sentences, each with 2-6 words familiar to

young children (e.g., “The bear sleeps. My airplane is small.”). One list is used per testing

session, during which the examiner reads a sentence aloud and the child repeats the sentence

aloud. In our study, the BIT was typically administered about halfway through a two-hour

session including frequent breaks between various linguistic, cognitive, and behavioral tests,

with parents observing in the same or an adjoining room. Examiners began with simple

instructions (e.g., “I’m going to read some sentences; I want you to listen and repeat them back

to me”) and prompted children between sentences as needed (e.g., “You say what I say.

Ready?”) BIT sessions were audio recorded in a quiet room directly to a solid-state digital

recorder using a table-top microphone set about 18 inches from the child’s mouth. The children’s

sentences were digitally extracted, RMS-normalized to minimize variations in loudness, and

stored for later playback, transcription, and scoring.

The intelligibility of each sentence was scored as the mean percentage of words correctly

identified via orthographic transcription by five or six naïve TH listeners. All listeners were

undergraduate native speakers of American English who reported no prior experience with deaf

speakers or CI users and who passed a hearing screening and transcription screening. They

received partial course credit or $10 for participation. Seated at a computer with sentences

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 10

presented over high-quality headphones, listeners orthographically transcribed what they thought

the child said after each sentence. Each sentence transcription was scored in terms of the

percentage of correctly-identified words, and the child’s speech intelligibility score for the

testing session was calculated as the mean of all sentence scores across all listeners. Because

many children did not repeat every word of each modeled sentence, scores were calculated

against only the words that the child attempted to produce, not the complete modeled sentence

(Ertmer, 2007). For example, it is well known that young children may omit articles, auxiliaries,

or inflectional morphemes (e.g., plural –s, third-person singular –s, past tense –ed) during

preschool stages of linguistic development, in both everyday productions and in repetition tasks

(Slobin & Welsh, 1973), so that a modeled sentence like “The baby cries” may be repeated as

“Baby cries” or “Baby cry” (Chin & Ting 2008). While a broad definition of speech

intelligibility may consider every core ability necessary to complete an elicited repetition task

(e.g., perceiving and repeating all words and segments accurately), the definition of speech

intelligibility used in this paper is narrower, focusing only on audio playback transcription, i.e.,

the number of whole words correctly recognized out of those that were actually produced by the

child.

BASC-2. The Behavior Assessment System for Children, Second Edition (BASC-2)

(Reynolds & Kamphaus, 2004) is a well-established measure of age-normed psychosocial

behavior that has been used in previous studies of various clinical pediatric populations,

including deaf children with CIs (Castellanos et al., 2016; Hoffman et al., 2016; Kronenberger et

al., 2016). The BASC-2 consists of rating scales of behavior problems and adaptive skills in

young people age 2-21 years, with parent reports for those under 18, teacher reports for all ages,

and self-reports for those in later school-age and older. Only parent reports were used in the

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 11

present studies. For each item, parents rate the child’s behavior over the last several months on a

0-3 scale (never, sometimes, often, almost always). Item scores are summed in categories that

form several Clinical Scales and several Adaptive Scales. Raw scores are then converted to T-

scores (M = 50, SD = 10) using age-based norms. For the Clinical Scales, T-scores above 60 are

considered “at-risk,” and scores above 70 are considered “clinically significant” problem areas.

For the Adaptive Scales, T-scores below 40 are considered “at-risk,” and scores below 30 are

considered “clinically significant.” Table 2 lists the BASC-2 scales on parent report forms for

each age group and key constructs covered by each. (Note that two scales do not appear on the

Preschool forms and were therefore only reported for the older children in Study 2.)

[INSERT Table 2 ABOUT HERE]

Procedure. Testing was conducted by licensed speech-language pathologists experienced

in testing deaf children with CIs

. Protocols were approved by the university’s institutional

review board, and children’s parents were consented prior to testing. During testing sessions,

parents reported demographic information (see Table 1) and completed checklists of their child’s

neurocognitive development and psychosocial behavior (including the BASC-2), while children

completed several performance tests of neurocognitive abilities and speech-language skills

(including the BIT). This report presents BIT and BASC-2 data for the first two annual visits in a

larger longitudinal study (Time 1, Time 2).

Data analysis. In order to address Research Question 1 (comparison of CI and TH

samples), BIT speech intelligibility scores and BASC-2 scale T-scores for the preschool CI and

TH samples were compared using Welch’s t tests, which do not assume equal variances between

samples. Pearson correlations were conducted within the CI sample in order to examine

Author contributions for both studies: all four authors contributed to study design and writing; the second and third

authors supervised data collection; the first author conducted analyses and initiated writing.

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 12

influences of demographic or hearing history factors on speech intelligibility. Unless otherwise

indicated, t tests and correlations reported in both studies were one-tailed, following the majority

of literature on CI users which has found poorer developmental outcomes for CI users compared

to TH peers and for CI users with various demographic/hearing traits (lower IQs and incomes,

later ages of implantation, greater pre-implant hearing loss, less emphasis on oral

communication, etc.).

In order to address Research Question 2 (relations between speech intelligibility and

psychosocial outcomes), Pearson correlations were used to identify significant relationships

between BIT and BASC-2 scores. Correlations were calculated separately within each sample

(CI or TH) and within and between testing times (Time 1 or Time 2). Correlations between BIT

and BASC-2 scores at the same time (e.g., Time 1–Time 1) reflect concurrent relations.

Correlations at different times reflect predictive relations of speech intelligibility on later

psychosocial outcomes (BIT Time 1 on BASC-2 Time 2) or vice versa (BASC-2 Time 1

predicting BIT Time 2).

Results

Comparison of samples on speech intelligibility and psychosocial functioning.

Speech intelligibility (BIT). The preschool CI and TH samples differed significantly in

speech intelligibility at both testing times (Time 1: t(31.87) = -5.53, Time 2: t(21.59) = -3.76,

both p < 0.001). Table 3 summarizes the BIT scores for each sample (means, SDs, ranges). The

TH sample displayed high speech intelligibility at both testing times (well above 70%), whereas

the CI sample displayed much lower mean scores. Within the CI sample, six

hearing/demographic factors were reliably related to speech intelligibility. BIT speech

intelligibility at Time 1 was correlated with nonverbal IQ (r(21) = .50, p < .01), family income

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(r(20) = .49, p < .05), age of implantation (r(22) = .43, p < .05), and length of CI use at Time 1

(r(22) = .39, p < .05), but none of these factors predicted BIT at Time 2. BIT scores at both times

were better for CI users with a greater oral communication mode score (Time 1: r(19) = .52, p <

.05; Time 2: r(19) = .52, p < .01). BIT scores at Time 2 were better for CI users who had two CIs

at Time 1 (r(19) = .50, p < .05; note that four bilateral CI users did not have data for Time 2, and

three additional CI users received a second CI between Times 1 and 2). None of the other

demographic factors listed in Table 1 reliably predicted BIT scores, including those often

associated with speech-language outcomes (e.g., chronological age, length of CI use, age at onset

of deafness, residual hearing level), perhaps due to their low variability or uneven distributions in

the sample and their involvement in the inclusion criteria.

[INSERT Table 3 ABOUT HERE]

Within the preschool TH control sample, speech intelligibility scores were consistently

high across participants. Figure 1 displays mean BIT speech intelligibility scores for individual

preschoolers, with CI users (gray) overlaid on TH participants (white), rank-ordered within each

sample and testing time. The majority of the TH sample scored above 70% at Time 1 (left), and

all scored above 70% at Time 2 (right; 70% indicated with a reference line). In contrast, CI users

varied substantially in speech intelligibility, and individuals improved to differing degrees from

Time 1 to Time 2 (range = 1% to 75% increases).

[INSERT Figure 1 ABOUT HERE]

Psychosocial adjustment (BASC-2). Within each preschool sample, two-tailed Welch’s t

tests revealed no significant differences between mean BASC-2 scale T-scores at Time 1 versus

Time 2 (all p > .05), suggesting that psychosocial development proceeded at a pace comparable

to that of age norms between annual testing times. Therefore, T-scores from Time 1 and 2 were

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 14

averaged for each participant before comparing BASC-2 patterns between samples and

subgroups. For the few participants who did not have BASC-2 scores at both testing times, the

single available T-score was used in place of a mean score. These cases included 3 CI

participants without Time 1 scores and 6 CI and 5 TH participants without Time 2 scores. Figure

2 displays the mean T-scores on each scale for the CI and TH samples, with shading to indicate

clinically “at-risk” ranges. While both samples had mean T-scores within the normal range (i.e.,

not “at risk”), the CI sample performed significantly more poorly on 8 of the BASC-2 scales (5

Clinical, 3 Adaptive): Hyperactivity (t(44.36) = 1.91, p < .05), Somatization (t(51.87) = 3.39, p <

.001), Attention Problems (t(51.04) = 3.16, p < .01), Atypicality (t(48.76) = 2.46, p < .01),

Withdrawal (t(53.91) = 1.89, p < .05), Adaptability (t(46.98) = -3.92, p < .001), Social Skills

(t(50.66) = -3.51, p < .001), and Functional Communication (t(40.28) = -6.38, p < .001, with

these significance levels indicated by stars in Figure 2).

[INSERT Figure 2 ABOUT HERE]

Relations between speech intelligibility and psychosocial outcomes. To assess the

links between speech intelligibility and psychosocial behaviors, Pearson correlations were

calculated between BIT and BASC-2 scores at both Time 1 and 2 without averaging across

testing times, in order to examine both concurrent and predictive relations. Table 4 lists the

correlations within the CI sample. BIT speech intelligibility scores had significant negative

correlations with three Clinical Scales and significant positive correlations with two Adaptive

Scales, indicating that better speech intelligibility was related to better (less clinical, more

adaptive) psychosocial behavior. BIT speech intelligibility scores at Time 1 were significantly

related to Atypicality and Adaptability at Time 1, Attention Problems, Atypicality, and

Withdrawal at Time 2, and Functional Communication at both Times 1 and 2. BIT scores at

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 15

Time 2 were significantly related to Atypicality, Withdrawal, and Adaptability at Time 2 and

Functional Communication at both times. These scales had some of the most elevated scores for

CI users and were among those that differed significantly between the CI and TH samples (see

Figure 2). In contrast, for the TH sample, only Aggression at Time 2 was significantly related to

BIT (Time 1: r(24) = -.39, p < .05; Time 2: r(23) = -.47, p < .01).

[INSERT Table 4 ABOUT HERE]

Study 2: School-Age Children and Teens

Study 2 sought to replicate and extend the major findings of Study 1 using an older

population of long-term CI users and TH peers. The participants in this study were part of a large

project on long-term outcomes for CI users in our lab. As part of this project, earlier studies

reported on the speech intelligibility ( Montag et al., 2014) and psychosocial adjustment (

Castellanos et al., 2016) of long-term school-age and teen CI users and TH peers; the current

study investigated relations between the two domains for a subset of participants, the 51 CI users

and 47 TH controls who had scores available for both measures (McGarr Sentence Intelligibility

and BASC-2 parent reports).

Method

Methods were similar to those in Study 1. Differences between the studies are listed in

Table 5.

[INSERT Table 5 ABOUT HERE]

Participants. Participants were enrolled in a larger investigation of long-term outcomes

in CI users; the samples for this study were long-term CI users and TH peers age 7 to 20 years.

CI users were recruited from current patient populations, participants in previous studies at the

same university-hospital-based clinic as in Study 1, and via professionals and schools in contact

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 16

with CI users. TH participants were recruited in the same local areas through flyers and emails

affiliated with the clinic and university. No participant was enrolled in both Study 1 and Study 2.

The cochlear implant sample (CI) consisted of 51 school-age children and teens with CIs

who fit the same inclusion criteria described for Study 1, with the following exceptions: onset of

deafness ranged up to 2 years of age, implantation occurred prior to age 7 years, CIs were used

for at least 7 years, and scores for speech intelligibility and psychosocial adjustment were

available from the single testing session. The TH control sample consisted of 47 participants

with typical hearing (assessed by basic audiometric screening) in the same age range and with

both types of scores available. Table 1 includes demographic and device information for these

two samples. Demographics for the CI sample were comparable with the TH sample (there were

no significant differences in age, nonverbal IQ, or family income via two-tailed Welch’s t tests,

all p > .05). Nonverbal IQ was assessed with Wechsler Abbreviated Scale of Intelligence Matrix

Reasoning subtest T-scores (M = 50, SD = 10); 25% of CI users scored above 60, 6% below 40,

while 28% of TH controls scored above 60 and none below 40. Family income was scored on the

same 10-point scale as in Study 1; 36% of CI users and 41% of TH controls had family incomes

at the highest two points (>$80,000/year), while 11% of CI users 41% of TH controls had

incomes in the lower half of the scale (<$35,000/year).

Between studies, the participants in Study 2 were older than those in Study 1 (t(130.34) =

-27.11, p < .001), but Study 1 and Study 2 participants did not differ in nonverbal IQ or family

income (two-tailed t tests, both p > .1). The CI users in Study 2 had used their CIs longer

(t(74.52) = -19.63, p < .001) and were implanted at older ages than the CI users in Study 1

(t(73.89) = -4.35, p < .001), but the CI samples did not differ statistically in age of onset of

deafness, communication mode, or hearing level (two-tailed, all p > .05).

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 17

Measures.

McGarr sentences. The McGarr Sentence Intelligibility Test (McGarr, 1981) is similar to

the BIT and has been implemented with CI users in previous work (Dawson et al., 1995; Geers,

2002; Osberger, Maso, & Sam, 1993; Tobey et al., 2003, 2011; Tobey & Hasenstab, 1991).

Participants repeat 36 short sentences which are both printed on cards and modeled orally.

Because the McGarr sentences were printed, participants in Study 2 did not rely entirely on the

examiner’s oral model, and they were able to correctly repeat the sentences. Sentence

intelligibility was assessed using the same playback-transcription method as in Study 1, with

each CI participant transcribed by three naïve listeners and each TH participant by one naïve

listener. Using the conventional method of averaging across transcribers to calculate a speech

intelligibility score for each participant resulted in very high scores across both samples. All TH

participants scored above 89% (M = 96%, SD = 2.3%, range = 89%–99%), as did 70% of CI

users (M = 89%, SD = 10.2%, range = 44%–97%). Due to the small variance in these

distributions, a stricter method of calculating participant speech intelligibility was used in Study

2, which we call “perfect-sentence intelligibility”: the proportion of a participant’s sentences

which were perfectly transcribed by all listeners. This resulted in a wider range of scores which

enabled analyses without ceiling effects.

BASC-2. As in Study 1, BASC-2 parent-reports were used for the school-age children

and teens in this study. The forms for these age groups (Child: ages 6-11, Adolescent: ages 12-

21) include the same scales as the Preschool parent-report form (ages 2-5) used in Study 1, with

age-appropriate adjustments (e.g., on the Functional Communication scale, all forms reference

communicating clearly, but only the Preschool form includes reciting the alphabet, and only the

Adolescent form includes making presentations to a group). The Child and Adolescent forms

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 18

also include two scales not used for preschoolers, Leadership and Conduct Problems, as noted in

Table 2.

Procedure. Procedures were the same as in Study 1. This report presents McGarr speech

intelligibility and BASC-2 parent-report data for a single testing session.

Data analysis. As in Study 1, in order to address Research Question 1 (comparison of CI

and TH), Welch’s t tests were used to compare the CI and TH samples on speech intelligibility

and psychosocial adjustment. For Research Question 2 (relations between speech intelligibility

and psychosocial adjustment), Pearson correlations were used to identify significant relations

between McGarr perfect-sentence scores and BASC-2 scales within each sample. Tests were

one-tailed unless otherwise indicated.

Results

Comparison of samples on speech intelligibility and psychosocial functioning.

Speech intelligibility (McGarr). Perfect-sentence speech intelligibility in the Study 2 TH

sample was high (M = 84%, SD = 6.4%, range = 69%–94%), indicating that the majority of

sentences were perfectly recognized by transcribers. Scores for the CI sample were lower and

more variable (M = 57%, SD = 19.3, range = 3%–81%). The difference between samples was

significant (t(61.82) = 9.39, p < .001). Within the CI sample, communication mode was

moderately correlated with McGarr perfect-sentence scores (r(49) = .60, p < .001); i.e., CI users

who relied more on oral skills had better speech intelligibility than those who also used sign.

None of the other hearing/demographic factors listed in Table 1 showed significant correlations

with McGarr perfect-sentence speech intelligibility. (However, for other analyses of

demographic factors in this population, see ( Montag et al., 2014).)

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 19

Figure 3 displays the McGarr perfect-sentence speech intelligibility scores for individual

Study 2 participants, rank-ordered by score with CI users (gray) overlaid on TH participants

(white). Similar to Study 1 preschoolers, the Study 2 TH sample showed consistently high

speech intelligibility, but CI users varied substantially. Nearly all Study 2 TH participants scored

above 70% (indicated with a reference line in Figure 3), while only a third of CI participants

reached this level.

[INSERT Figure 3 ABOUT HERE]

Psychosocial adjustment (BASC-2). As previously noted, the CI and TH samples in

Study 2 were subsets of larger samples for which BASC-2 scores were previously reported (

Castellanos et al., 2016). In that report, the larger CI sample scored significantly more poorly

than the TH sample on every BASC-2 scale except Anxiety and Somatization (two-tailed t tests,

all p < .05). The same pattern was also found for the slightly smaller samples in the current

study. Figure 4 displays the mean T-scores on each scale for the Study 2 CI and TH samples,

with shading to indicate clinically “at-risk” ranges and stars to indicate the significance levels by

which the samples differed on each scale (one-tailed Welch’s t tests). Both samples had mean T-

scores within the normal range (i.e., not “at-risk”).

[INSERT Figure 4 ABOUT HERE]

Relations between speech intelligibility and psychosocial outcomes. Several

significant correlations were uncovered between McGarr perfect-sentence intelligibility scores

and BASC-2 psychosocial adjustment scales—9 in the CI sample and 7 in the TH sample, as

shown in Table 6. The significant negative correlations with Clinical Scales (Anxiety,

Depression, Withdrawal) and significant positive correlations with Adaptive Scales

(Adaptability, Activities of Daily Living, Functional Communication) indicate that better speech

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 20

intelligibility was associated with more positive psychosocial adjustment in these samples. Five

scales showed significant correlations only within the CI sample (Anxiety, Withdrawal,

Adaptability, Leadership, Activities of Daily Living), three within only the TH sample

(Hyperactivity, Aggression, Conduct Problems), four within both samples (Depression, Attention

Problems, Atypicality, Functional Communication), and two within neither sample

(Somatization, Social Skills).

[INSERT Table 6 ABOUT HERE]

Discussion

These two studies revealed differences in speech intelligibility and psychosocial

functioning between children and teens with CIs and TH peers. Both studies also found relations

between speech intelligibility and several domains of psychosocial functioning in samples of CI

users at both preschool and later ages (school-age and teen).

Research Question 1: Comparison of Samples on Speech Intelligibility and Psychosocial

Functioning

Consistent with our hypotheses, CI users in both studies showed poorer speech

intelligibility and psychosocial adjustment than TH peers, but with considerable individual

variation in the CI samples, some CI users performed similarly to TH peers. Performance among

TH preschoolers in Study 1 reached about 70% using the traditional measure of average words

correctly transcribed, and all TH and CI participants improved from one testing year to the next,

as would be expected for this period of rapid phonological development. By school age, TH

performance using the same measure reached about 90%, prompting the implementation of the

stricter method of speech intelligibility scoring for Study 2. However, the patterns of

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 21

performance as high across TH participants and variable across CI users remained within each

study regardless of the measure.

Study 1 preschool CI users showed poorer psychosocial adjustment than TH peers in

domains most closely related to communication and executive functioning but did not differ

from TH peers in other areas. In Study 2, the school-age/teen CI sample’s psychosocial

adjustment was close to the norm but significantly poorer than TH sample scores on all but two

scales. This may reflect difficulties in navigating the increased complexity of social interaction

and greater importance of peers in later childhood and teenage years. CI users may be at a

disadvantage in group interactions, for example, which pose especially difficult listening

environments for CI users, requiring greater concentration and increasing the likelihood of

missed social cues needed for learning complex social skills.

Research Questions 2 and 3: Relations between Speech Intelligibility and Psychosocial

Outcomes in Preschool and School-Age/Teen CI Users

Study 1 uncovered links between speech intelligibility at two testing time points and

psychosocial adjustment. Within the CI sample, five of the BASC-2 scales were correlated with

BIT speech intelligibility. Study 2 provided converging evidence in an older sample of long-term

CI users, who showed relations between McGarr perfect-sentence speech intelligibility and nine

BASC-2 scales, including all five scales that were related to speech intelligibility in the Study 1

preschool CI sample. The inclusion of four additional scales may reflect the cumulative effects

of poor speech intelligibility on psychological well-being and independent living skills in

children with CIs as they mature. These results establish the first links between audio-

transcription measures of speech intelligibility (BIT and McGarr sentences) and psychosocial

behaviors (BASC-2 parent-reports) in deaf children with CIs.

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 22

Most of the BASC-2 scales that were related to speech intelligibility in one or both

studies (e.g., Functional Communication, Atypicality, Withdrawal, Adaptability, Activities of

Daily Living, Leadership, Attention Problems) involve a core component of social or

communication functioning, which would likely be influenced by speech intelligibility. For

example, the relations between speech intelligibility and the BASC-2 Functional Communication

scores in both studies are unsurprising, given that several questions on this scale deal specifically

with clarity of speech and effective information transmission. This scale also involves pragmatic

skills such as responding appropriately to questions, explaining game rules, and relating personal

narratives. Previous work has found delays in children with hearing loss in their mastery of

pragmatic skills such as maintaining a conversational topic or flow, turn-taking, responding as a

listener, and repairing misunderstandings (Jeanes, Nienhuys, & Rickards, 2000; Most, Shina-

August, & Meilijson, 2010; Tye-Murray, 2003). While hearing loss may contribute to missing

conversational cues, difficulties with speech intelligibility may cause misunderstandings and

disrupt conversational flow or narrative clarity. At preschool ages, for example, children with

more intelligible speech may have more efficient and effective communication with other

children, providing them with more shared experiences of communication, psychological, and

emotional functioning. These latter influences on shared psychological and emotional

experiences may accumulate over time, explaining some of the relations with emotional

functioning (e.g., anxiety and depression) found for long-term CI users in Study 2.

Atypicality was correlated with CI user speech intelligibility in both studies. Like the

Functional Communication scale, some items on the Atypicality scale may be impacted by

parents’ understanding of the child’s linguistic behavior (e.g., babbling to self, nonsensical

utterances), and items such as those regarding strange or confused behavior or apparent

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 23

unawareness of others could reflect a breakdown in the speech-communication chain involving

either hearing or interactional components.

Attention problems were also correlated with CI user speech intelligibility in both

studies. Some items on the Attention Problems scale (e.g., regarding listening carefully or paying

attention when being addressed) may reflect difficulties with another link in the speech chain—

hearing and understanding elementary speech cues, which are sparsely encoded by CIs. Previous

studies have identified delays in executive functioning—including controlled attention—in

children and teens with CIs, and there is evidence that speech and language functioning deficits

are significant contributors to these delays (Figueras, Edwards, & Langdon, 2008; Kronenberger,

Pisoni, Henning, & Colson, 2013). Thus, a finding that speech intelligibility is related to

attention problems is consistent with that prior research, although prior research has focused

more on receptive language components rather than intelligibility.

Several BASC-2 scales reflecting social and communication functioning were correlated

with CI user speech intelligibility—Withdrawal and Adaptability in both studies and Activities

of Daily Living and Leadership in Study 2. Furthermore, some more emotionally-focused

BASC-2 scales (Anxiety, Depression) were related to speech intelligibility only in the older

sample examined in Study 2. It may be that at older ages, language skills and the social benefits

of language interactions have a broader impact on a wide range of psychosocial functions,

including emotional adjustment and independent living. There may also be a cumulative

developmental effect of poor speech intelligibility on emotional well-being that takes time to

develop and that becomes apparent only after higher levels of cognitive functioning are attained.

School ages and teenage years are developmental periods characterized by demands on

emotional coping skills and social competence with increased group social interaction and less

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 24

support from parents and authorities compared to preschool ages. Thus, effective communication

relying on good speech intelligibility may be an important tool for acquiring social support and

for engaging in adaptive coping behaviors that promote emotional and social adjustment. In

addition, difficulties in these areas may be sources of anxiety and depression, particularly as

worries about fitting in and being accepted by peers become more salient during teenage years.

In Study 2, several BASC-2 scales were correlated with speech intelligibility within the

TH sample. Three of these scales also showed relations within the Study 2 CI sample

(Depression, Withdrawal, Functional Communication), but the three other scales did not show

relations among CI users in either study: Hyperactivity, Aggression, and Conduct Problems,

although Aggression was related to speech intelligibility among TH preschoolers in Study 1.

These three scales constitute an Externalizing Problems composite on the BASC-2 and measure

overactive, disruptive, intrusive, and rule-breaking behaviors.

Finally, two BASC-2 psychosocial adjustment scales did not correlate with speech

intelligibility in either study: Somatization and Social Skills. Somatization reflects broad

physical complaints extending well beyond hearing loss or communication delays related to

speech intelligibility. The lack of significant relations with social skills was unexpected given the

importance of intelligibility for social interaction. It could be that parents’ views of their

children’s attempts to be polite and helpful may include nonverbal cues and other behaviors

independent of good intelligibility; this scale and its components will be investigated more

closely in future research.

Implications and Clinical Relevance

The results of these two studies suggest that several areas of psychosocial development

are at elevated risk for young CI users who display poor speech intelligibility, whereas CI users

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 25

with consistently good speech intelligibility over time, especially during preschool ages,

experience more positive psychosocial outcomes. Thus, it is clinically important that deaf

children with CIs who display poor speech intelligibility also be evaluated and monitored closely

for possible risk and problems in psychosocial development. The measures of speech

intelligibility and psychosocial adjustment used in these studies are relatively brief and

straightforward to administer and interpret, further enhancing the clinical utility of the present

results.

Because the relations identified in this study were correlational in nature, it is unknown if

improvements in speech intelligibility positively affect psychosocial behaviors, if better

psychosocial skills enable speech intelligibility improvement, or if the two develop together.

What is clear, however, is that difficulties in the two domains are related. Because speech

intelligibility is considered as an important outcome for CI users, it is often targeted in speech-

language therapy, but difficulties with psychosocial behaviors may not receive attention unless

they reach clinically-significant levels. Based on the current findings, additional attention to

psychosocial outcomes is warranted, and psychosocial adjustment should be a focus of

evaluation in children who display poor speech intelligibility after cochlear implantation.

Limitations and Future Directions

As with many studies of clinical populations, random sampling is difficult or impossible

to achieve, and multiple factors contribute to speech and language outcomes in CI users. By

design, the samples in these studies restricted the range of several such variables (age of onset of

deafness, age of implantation, residual hearing, etc.) to allow more straightforward comparisons

of factors that have not been investigated in the past. However, this may have resulted in smaller

sample sizes, especially in Study 1, which were further reduced over time as some participants

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 26

failed to return each year. In addition, factors that were not evenly matched between samples or

studies may impact the results reported here (e.g., age at implantation, length of CI use,

nonverbal IQ, family income, communication mode, educational setting). Although age and

length of CI use were not correlated with the outcome measures, the ranges of these factors were

large and may be a concern for accurate tracking of development or improvement in both speech

intelligibility and psychosocial adjustment, especially given the large changes in social and

family relationships that occur between early childhood and teenage years. Future work on

speech intelligibility and psychosocial outcomes should use larger, more controlled, more

diverse samples to systematically evaluate factors that may affect those outcomes and to provide

statistical analyses with greater power.

The similarity of the patterns found among the two different age groups using different

measures of speech intelligibility supports the generalizability of the present results, but with

some limitations. Speech intelligibility was measured from audio recordings only, but many real-

life situations have the added benefit of visual speech information to enhance intelligibility, and

so CI users may fair better outside research/clinical settings. However, both CI and TH talkers

likely experience higher intelligibility in face-to-face communication (in which listener feedback

also aids in mutual comprehension), but the least intelligible CI users are likely to remain less

intelligible than their peers. Similarly, difficult listening environments (e.g. noisy restaurants,

phone conversations with strangers) negatively affect all talkers’ intelligibility, with the least

intelligible likely suffering most; these factors should be examined directly in future work. It is

also possible that differences in BIT and McGarr test administration (i.e., oral/pictoral vs.

oral/printed sentence presentation, short vs. varying in length and predictability) differentially

affected speech intelligibility scores between the two studies. Similarly, items that differ between

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 27

BASC-2 forms for the different age groups may have an effect, albeit limited, given the use of

age-based T-score norms. Finally, because many parents observe and interact with their children

far more during preschool than older ages, parent reports may not fully capture aspects of

psychosocial behavior that manifest in school settings. For this reason, teacher reports of the

BASC-2 are often solicited during clinical evaluations (Reynolds & Kamphaus, 2004).

These studies support a clinical approach of incorporating assessment of psychosocial

adjustment into routine evaluation of deaf children with CIs, particularly when speech

intelligibility deficits are present. Future work is needed to design and investigate treatment

options to improve psychosocial adjustment, possibly through the use of speech-language

interventions. Intervention research involving speech intelligibility and psychosocial adjustment

will also provide better insight into the causal links between these critical outcomes.

Conflicts of Interest

No conflicts of interest are reported.

Funding

This work was supported by grants from the National Institutes of Health—National

Institute on Deafness and Other Communication Disorders [R01 DC009581, T32 DC00012].

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 37

Tables

Table 1

Sample descriptions for Study 1 preschool and Study 2 school-age/teen participants.

Study 1

Study 2

Variable CI TH

CI TH

Total N 27 30

51 47

N at Time 1/Time 2 24/21 30/25

Sex (N; male/female) 15/12 16/14

27/24 21/26

Nonverbal IQ

at Time 1 53.9 (10.0)

(33–81)

59.7 (12.2)

(41–81)

54.9 (7.8)

(32–68)

55.2 (7.3)

(40–70)

Family income

at Time 1 6.8 (3.1)

(1–10)

7.2 (2.0)

(1–10)

7.4 (2.3)

(2–10)

7.7 (2.3)

(1–10)

Age at Time 1 (years) 4.3 (1.1)

(3.1–6.9)

4.2 (0.9)

(3.1–7.0)

13.2 (3.1)

(7.8–19.1)

13.0 (2.8)

(7.1–19.8)

Age at Time 2 (years) 5.2 (1.0)

(4.1–7.9)

5.1 (0.8)

(4.1–7.2)

Age change Time 1-2 (years) 1.0 (0.2)

(0.5–1.4)

1.0 (0.2)

(0.6–1.5)

Years of CI use at Time 1 2.8 (1.1)

(0.5–5.2)

10.8 (2.5)

(7.2–16.0)

Years of CI use at Time 2 3.8 (1.1)

(1.5–6.1)

Onset of deafness (months) 0.1 (0.4)

(0–2.0)

1.4 (5.0)

(0–24.0)

Age at implantation (months) 18.6 (7.6)

(8.0–36.6)

31.1 (17.6)

(8.3–75.8)

Best pre-implant PTA 101.3 (13.7)

(73.3–118.4)

106.9 (11.7)

(85.0–118.4)

Communication mode

4.9 (0.6)

(2–5)

4.7 (0.8)

(2–5)

Bilateral CI (N; Time 1/2) 19/20

CI model/processing strategy (N)

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CC Nucleus / ACE 23

CC Nucleus / SPEAK

ABC Clarion / HiRes 3

ABC Clarion / MPS

ME Opus II / FSP 1

ME Opus II / CIS

Note. Values are Means (SDs) above (ranges), unless otherwise indicated. PTA = pure tone average (dB hearing

loss); TC = Total Communication (speech + sign); CC = Cochlear Corporation; ACE = Advanced Combination

Encoder; SPEAK = Spectral Peak; ABC = Advanced Bionics Corporation; HiRes = High Resolution; MPS =

Multiple Pulsatile Stimulation; ME = Med-El Corporation; FSP = Fine Structure Processing; CIS = Continuous

Interleaved Sampling.

Nonverbal IQ in Study 1: T-score from the Differential Ability Scales, II Picture Similarities subtest (Elliot, 2007);

in Study 2: T-score from the Wechsler Abbreviated Scale of Intelligence Matrix Reasoning subtest.

Income is coded on a 1-10 scale (<$5,000/year to >$95,000/year).

Communication mode is coded on a 1-6 scale (mostly sign to auditory-oral) (Geers, 2002).

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 39

Table 2

BASC-2 scales and constructs covered in parent report forms for each age group.

BASC-2 scale Age Important constructs covered

Clinical Scales

Hyperactivity P, C, A Self-control, impatience, fidgeting

Aggression P, C, A Bullying, temper, physical outbursts

Conduct Problems C, A Discipline problems

Anxiety P, C, A Worrying, fearfulness, perfectionism

Depression P, C, A Moodiness, negativity

Somatization P, C, A Illness, physical complaints

Attention Problems P, C, A Attention span, distractibility

Atypicality P, C, A Strange behavior, inappropriate emotions

Withdrawal P, C, A Shyness, social avoidance

Adaptive Scales

Adaptability P, C, A Adjusting to changes, recovering from setbacks

Social Skills P, C, A Politeness, helpfulness, encouraging others

Leadership C, A Decision-making, group participation

Activities of Daily Living P, C, A Daily routines, personal safety, cleanliness

Functional Communication

P, C, A Speaking clearly, communicating appropriately

Note. P = preschool (ages 2-5), C = child (ages 6-11), A = adolescent (ages 12-21).

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 40

Table 3

BIT speech intelligibility scores (in %) for Study 1 preschool CI and TH samples.

Variable CI TH

N at Time 1/Time 2 24/21 30/25

BIT score at Time 1 50.7 (27.1)

(0.8–95.5)

84.1 (13.4)

(52.1–99.3)

BIT score at Time 2 67.7 (27.1)

(6.1–98.0)

90.4 (5.9)

(75.9–98.3)

Note. BIT scores are percent of words correctly transcribed, Means (SDs) above (ranges).

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 41

Table 4

Correlations between BIT speech intelligibility and BASC-2 scale scores within the Study 1 preschool CI sample.

BIT T1 BIT T2

BASC-2 Scale

BASC T1

(N = 22)

BASC T2

(N = 20)

BASC T1

(N = 20)

BASC T2

(N = 19)

Clinical Scales

Hyperactivity -0.05

0.15

0.32

0.21

Aggression -0.25

-0.03

-0.07

0.23

Anxiety -0.07

-0.10

0.06

0.16

Depression -0.17

0.01

-0.09

0.18

Somatization -0.21

-0.03

-0.37

-0.16

Attention Problems -0.33

-0.50

* -0.01

-0.26

Atypicality -0.42

* -0.39

* -0.28

-0.65

Withdrawal -0.24

-0.40

* -0.14

-0.40

Adaptive Scales

Adaptability 0.36

* 0.34

0.37

0.43

Social Skills 0.22

0.21

0.17

Activities of Daily Living -0.32

-0.09

-0.20

-0.12

Functional Communication 0.72

***

0.76

***

0.51

* 0.67

* p < .05. ** p < .01. *** p < .001.

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 42

Table 5

Comparison of methods used in Study 1 and Study 2.

Method Study 1 Study 2

Participant age range Preschool (age 3-6) School-age/Teen (age 7-20)

Data set origin Longitudinal project on early-

implanted CI users and peers

Project on long-term CI users

and peers

Testing schedule Tested annually; data

available for first 2 years

Tested once

Intelligibility test BIT: 10 sentences repeated

after live-voice model

McGarr: 36 sentences read and

repeated after live-voice model

Intelligibility scoring

Traditional: Percentage of

words correctly transcribed,

averaged across listeners

Perfect-sentence: Percentage of

sentences perfectly transcribed

by all listeners

Psychosocial test BASC-2 parent report for

preschoolers

BASC-2 parent reports for

children or teens (including 2

scales not used for preschoolers)

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INTELLIGIBILITY AND PSYCHOSOCIAL FUNCTIONING 43

Table 6

Correlations between McGarr perfect-sentence intelligibility and BASC-2 scale scores within each Study 2 school-

age/teen sample.

BASC-2 Scale CI (N=51) TH (N=47)

Clinical Scales

Hyperactivity -0.18

-0.40

Aggression -0.20

-0.32

Conduct Problems -0.03

-0.31

Anxiety -0.29

* 0.08

Depression -0.36

** -0.29

Somatization -0.17

0.23

Attention Problems -0.34

** -0.26

Atypicality -0.32

-0.52

***

Withdrawal -0.40

** 0.02

Adaptive Scales

Adaptability 0.26

* 0.13

Social Skills 0.20

0.07

Leadership 0.38

0.03

Activities of Daily Living 0.37

** 0.23

Functional Communication 0.57

*** 0.35

* p < .05. ** p < .01. *** p < .001.

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Individual BIT speech intelligibility scores, Time 1 (left), Time 2 (right), Study 1 CI users (gray) overlaid on

TH preschoolers (white). Reference line at 70% indicates good performance.

Figure 1

203x76mm (300 x 300 DPI)

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Mean BASC-2 scores by scale, averaged across Times 1 and 2, Study 1 preschool CI and TH samples.

Asterisks indicate scales that differ significantly between samples (* p < .05, ** p < .01, *** p <.001, one-

tailed Welch’s t tests).

Figure 2

209x100mm (300 x 300 DPI)

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Individual McGarr speech intelligibility scores, Study 2 CI users (gray) overlaid on TH participants (white).

Reference line at 70% indicates good performance.

Figure 3

177x69mm (300 x 300 DPI)

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Mean BASC-2 scores by scale, Study 2 CI and TH samples. Asterisks indicate scales that differ significantly

between samples (* p < .05, ** p < .01, *** p <.001, one-tailed Welch’s t tests).

Figure 4

234x100mm (300 x 300 DPI)

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Speech Intelligibility in Children with Cochlear Implants Compared to Normal-Hearing Peers Matched for Chronological Age and Hearing Age

Article

Full-text available

Jun 2022

Background and Aim: Cochlear implants (CIs) can lead to the development of verbal communication in areas such as sound repertoire, speech intelligibility (SI), and conversational skills. The SI refers to the ability to make recognizable speech sounds. Children with CIs may experience poorer SI than normalhearing (NH) children. This study aims to compare the SI between children with CIs and NH peers matched for chronological age and hearing age. Methods: The speech samples of 40 monolingual Persian-speaking children, including 20 children with CIs and 20 NH children were used in this study. The children’s SI was analyzed using three measures of the percentage of correct consonants, percentage of correct vowels, and percentage of intelligible words. One speech-language pathologist and two non-professional listeners transcribed each speech sample. Results: The results showed no significant difference in any measures of SI between CI children and NH hearing age-matched peers, but there was a significant difference between CI children and NH chronological age-matched peers (p

Spontaneous speech intelligibility: early cochlear implanted children versus their normally hearing peers at seven years of age

Article

Dec 2021

Speaking intelligibly is an important achievement in children’s language development. How far do congenitally severe-to-profound hearing-impaired children who received a cochlear implant (CI) in the first two years of their life advance on the path to intelligibility in comparison to children with typical hearing (NH)? Spontaneous speech samples of children with CI and children with NH were orthographically transcribed by naïve transcribers. The entropy of the transcriptions was computed to analyze their degree of uniformity. The same samples were also rated on a continuous rating scale by another group of adult listeners. The transcriptions of the NH children’s speech were more uniform, i.e., had significantly lower entropy, than those of the CI children, suggesting that the latter group displayed lower intelligibility. This was confirmed by the ratings on the continuous scale. Despite the relatively restricted age ranges, older children reached better intelligibility scores in both groups.

Socio-Emotional Development of Children with Cochlear Implant: A Systematic Review

Article

Full-text available

Oct 2021

Background: Attaining socio-emotional competence is challenging for children with hearing impairment. There is wide recognition of children with cochlear implant (CI) indicating significant improvement in their speech and language abilities, however many factors may restrict their chance of having reciprocal social interactions. A significant improvement in speech and language does not automatically affirm the quality of social interactions. This present observation on social-emotional development addressed a more current representative population of children with hearing loss who have benefitted from cochlear implantation. Methods: The research conducted a systematic review of selected articles from Scopus and PubMed databases, retrieved through three search-process keywords, namely socio-emotional, children and CI. The inclusion criteria only included journal articles published in English with empirical data from the year 2010-2019. The initial search had identified 189 potential abstracts and after removal of duplicates, only 38 eligible studies met the inclusion criteria. Results: Among 38 studies reviewed, 19 studies showed comparable socio-emotional skills with peers in social interaction, empathy, emotion theory of mind and comprehension skills. Conversely, the other 19 studies presented underprivileged results in socio-emotional functioning mainly in identifying facial expression, regulating emotion and emotional cues in the auditory domain. Conclusion: This review concluded that the socio-emotional development among children with CI, both at preschool-age and school-age, was not justified due to the heterogeneity in studies across measurement and small sample size. Also, the conclusion recommended extensive cross-referencing, mixed-mode research design, detailed distinguishing of socio-emotional functioning and identification of diverse groups of the population with impaired hearing as an approach to provide empirical evidence on socio-emotional functioning among children with CI in the future.

Intelligibility of Word-Initial Obstruent Consonants in Mandarin-Speaking Prelingually Deafened Children With Cochlear Implants

Article

May 2023

Purpose This study assessed the intelligibility of obstruent consonants in prelingually deafened Mandarin-speaking children with cochlear implants (CIs). Method Twenty-two Mandarin-speaking children with normal hearing (NH) aged 3.25–10.0 years and 35 Mandarin-speaking children with CIs aged 3.77–15.0 years were recruited to produce a list of Mandarin words composed of 17 word-initial obstruent consonants in different vowel contexts. The children with CIs were assigned to chronological age–matched (CA) and hearing age–matched (HA) subgroups with reference to the NH controls. One hundred naïve NH adult listeners were recruited for a consonant identification task that consisted of a total of 2,663 stimulus tokens through an online research platform. For each child speaker, the consonant productions were judged by seven to 12 different adult listeners. An average percentage of consonants correct was calculated across all listeners for each consonant. Results The CI children in both the CA and HA subgroups showed lower intelligibility in their consonant productions than the NH controls. Among the 17 obstruents, both CI subgroups showed higher intelligibility for stops, but they demonstrated major problems with the sibilant fricatives and affricates and showed a different confusion pattern from the NH controls on these sibilants. Of the three places (alveolar, alveolopalatal, and retroflex) in Mandarin sibilants, both CI subgroups showed the lowest intelligibility and the greatest difficulties with alveolar sounds. For the NH children, there was a significant positive relationship between overall consonant intelligibility and chronological age. For the children with CIs, the best fit regression model revealed significant effects of chronological age and age at implantation, with their quadratic terms included. Conclusions Mandarin-speaking children with CIs experience major challenges in the three-way place contrasts of sibilant sounds in consonant production. Chronological age and the combined effect of CI-related time variables play important roles in the development of obstruent consonants in the CI children.

Employers' Speech-Based First Impressions of Cochlear Implant Users

Article

Full-text available

Oct 2022
J DEAF STUD DEAF EDU

Valerie Freeman

This study is part of a series on speech-based first impressions of prelingually deaf cochlear implant (CI) users with differing speech intelligibility. Hiring managers with typical hearing (TH) rated CI users and TH young adults on various personality traits and suitability as job applicants after hearing recorded speech samples. Similar to prior peer listeners, managers rated TH speakers more positively than highly intelligible CI users (CI-Hi), with less-intelligible CI users rated even more negatively. Managers for white-collar or high-communication jobs rated CI-Hi lower than did managers of blue-collar or low-communication jobs. Positive attitudes and experience with deafness improved ratings of CI users. While underlining the importance of intelligibility, these patterns also highlight the impact of listeners' underlying attitudes on their initial judgments of CI users, which could affect deaf employment opportunities. The study calls for workplace education about hearing loss and deaf communication to improve deaf inclusion and employment rates.

Speech intelligibility of children with an auditory brainstem implant: a triple-case study

Article

Apr 2022

Auditory brainstem implantation (ABI) is a relative recent development in paediatric hearing restoration. Consequently, young-implanted children's productive language has not received much attention. This study investigated speech intelligibility of children with ABI (N = 3) in comparison to children with cochlear implants (CI) and children with typical hearing (TH). Spontaneous speech samples were recorded from children representing the three groups matched on cumulative vocabulary level. Untrained listeners (N = 101) rated the intelligibility of one-word utterances on a continuous scale and transcribed each utterance. The rating task yielded a numerical score between 0 and 100, and similarities and differences between the listeners' transcriptions were captured by a relative entropy score. The speech intelligibility of children with CI and children with TH was similar. Speech intelligibility of children with ABI was well below that of the children with CI and TH. But whereas one child with ABI's intelligibility approached that of the control groups with increasing lexicon size, the intelligibility of the two other children with ABI did not develop in a similar direction. Overall, speech intelligibility was only moderate in the three groups of children, with quite low ratings and considerable differences in the listeners' transcriptions, resulting in high relative entropy scores.

Longitudinal effects of emotion awareness and regulation on mental health symptoms in adolescents with and without hearing loss

Article

Full-text available

Feb 2022
EUR CHILD ADOLES PSY

Emotion awareness (EA) and regulation (ER) are each known to associate with mental health symptoms, yet there is a paucity of longitudinal studies examining them jointly during adolescence. Furthermore, little is known about these skills and their relations in deaf and hard-of-hearing (DHH) adolescents, who are at risk for reduced emotion socialization and for more mental health symptoms. This longitudinal study examined the development and unique contributions of EA (emotion differentiation, emotion communication and bodily unawareness) and ER (approach, avoidance and worry/rumination) to internalizing and externalizing symptoms in adolescents with and without hearing loss. Using self- and parent's reports, we assessed 307 adolescents (age 9–15) three times over 18-month period. We found stability over time in development of EA and avoidance ER, increase in approach ER and decrease in worry/rumination. High levels and increases over time in two aspects of EA, emotion differentiation and communication, and in approach and avoidance ER were related to decreases in depressive symptoms. An increase in approach ER was also related to a decrease in anxiety symptoms. Yet, low levels or decreases in worry/rumination were related to decreased levels of depressive, anxiety and externalizing symptoms. Hearing loss did not moderate any of the variables or relations tested. Preliminary tests suggested heterogeneity within the DHH group according to educational placement, language abilities and parental education level. Overall, findings pointed at unique contributions of EA and ER to mental health development, suggesting that DHH adolescents, especially in mainstream schools, do not differ from their hearing peers in their emotion awareness and regulation.

The effects of vestibular dysfunction on balance and self-concept in children with cochlear implants

Article

Jul 2023
Int J Pediatr Otorhinolaryngol

Objectives: Children with cochlear implants (CCI) have an increased rate of vestibular dysfunction. Vestibular dysfunction is associated with decreased balance and dynamic visual acuity ability. Hearing loss alone is associated with reduced speech perception and vocabulary in children. In adults, vestibular dysfunction is associated with reduced quality of life; however, similar relationships have not been studied in children with vestibular dysfunction. Therefore, the objective of the present study was to evaluate the effect of hearing loss and vestibular dysfunction on self-concept in CCI (n = 33) compared to children with normal hearing (CNH, n = 38). It was hypothesized that children with vestibular dysfunction would have reduced self-concept beyond that from hearing loss, secondary to the presence of balance and visual acuity deficits. Methods: The Piers-Harris Children's Self-Concept Scale - 2, speech perception, vocabulary, video head impulse test (vHIT), rotary chair, balance using the Bruininks-Oseretsky Test of Motor Proficiency (BOT-2), and dynamic visual acuity (DVA) testing were completed on all participants. Results: In the 34 CCI, 24 had normal vestibular function, 6 had unilateral vestibular dysfunction, and 4 had bilateral vestibular dysfunction. There were no significant mean differences in the Piers-Harris Children's Self-Concept Scale - 2 between groups. A Principal Component Analysis (PCA) was conducted on the predictor variables (average horizontal canal vHIT gain, BOT-2 score, DVA, speech perception, and vocabulary) resulting in two factors; factor 1 represented "vestibular" components (vHIT, BOT-2, and DVA) and factor 2 represented "auditory-language" components (speech perception and vocabulary). In addition to age and gender, the 2 PCA factors were analyzed using multivariate regression with stepwise selection to determine which factors best predicted self-concept. The PCA auditory-language factor was the only significant predictor of self-concept. Conclusions: Auditory-language, not vestibular related factors, contribute to the self-concept of CCI. While adults with vestibular dysfunction have reduced quality of life, it could be that children with vestibular dysfunction have some psychosocial resilience.

Predicting Quality of Life and Behavior and Emotion from Functional Auditory and Pragmatic Language Abilities in 9-Year-Old Deaf and Hard-of-Hearing Children

Article

Full-text available

Nov 2021

Children who are deaf or hard of hearing (DHH) are likely to exhibit difficulties in development of psychosocial skills, pragmatic language skills, and use of hearing for social communication in real-world environments. Some evidence suggests that pragmatic language use affects peer-relationships and school engagement in these children. However, no studies have investigated the influence of functional auditory performance and use of language and speech in real-world environments on children’s behavior and emotion, and on their health-related quality of life. This study explored the relationship in DHH children at 9 years of age. Data from 144 participants of the Longitudinal Outcomes of Children with Hearing Impairment study were analyzed. Parent reports were obtained on quality of life, behavior and emotion, pragmatic language skills, and auditory functional performance of children in real life. Children’s spoken language abilities and speech intelligibility were assessed by research speech pathologists. On average, performance of children in all domains was within the range of typically developing peers. There were significant associations among functional auditory performance, use of speech and language skills, psychosocial skills, and quality of life. Multiple linear regression analyses revealed that better auditory functional performance and pragmatic language skills, rather than structural language abilities, were associated with better psychosocial abilities and quality of life. The novel findings highlight the importance of targeted intervention for improving functional hearing skills and social communication abilities in DHH children, and emphasize the importance of collaborative approaches among medical, audiology, allied health, and educational professionals to identify those at risk so that timely referral and intervention can be implemented for improving psychosocial health and well-being in DHH children.

Collaboration Between Child Play Therapy and Speech-Language Pathology: Case Reports of a Novel Language and Behavior Intervention

Article

Oct 2021

Purpose It has been well documented that a significant number of children with developmental language disorders (DLDs) also exhibit challenging behaviors. In this study, a new intervention (Play and Language [PAL]) was developed through a research collaboration between a speech-language pathologist and a play therapist. The purpose of this clinical focus article is to describe child play therapy techniques and how these, along with early language intervention techniques, may positively impact preschool children's general communication and behavior. Method Students in a communication sciences and disorders program were trained to use a combination of child therapy techniques and language facilitation procedures in the PAL approach. Five preschool children, who displayed DLD and challenging behaviors, participated in a 2-week daily intensive intervention. Pre- and postintervention data for general communication and behavior skills were collected through parent report and language sample data. Student clinician and parent surveys were collected to assess the feasibility of conducting the new intervention and the parent-observed outcomes and satisfaction. Results A majority of the children who participated in the study increased their intelligibility and number of different words. Fewer than half increased their sentence length. These same children decreased their challenging behaviors, with 11 of 14 behaviors being reduced to normal levels. All parents reported satisfaction with their child's results. In addition, students trained to provide the intervention reported high levels of satisfaction with the training to implement PAL and that they were confident in providing the intervention techniques. Conclusion Together, our exploratory data provide preliminary and limited evidence that combining play therapy and language facilitation techniques may improve general communication skills and decrease challenging behaviors within the same intervention. Supplemental Material https://doi.org/10.23641/asha.16840459

Comparisons of Longitudinal Trajectories of Social Competence

Article

Full-text available

Nov 2016

Objective: To evaluate the longitudinal effects of cochlear implantation (CIs) on young, deaf children’s social competence over 5 years of implant use and compare their social skills to those of same-aged, hearing peers. Study Design: Prospective, longitudinal between- and within-subjects design, with assessments completed 3 times over 5 years. Setting: This study was conducted at 6 cochlear implant centers and two preschools that enrolled both CI and hearing children. Patients: Parents of 132 children with CIs and 67 agematched hearing controls completed the study measures. Children were between 5 and 9 years of age at the first time point. Interventions: Cochlear implantation and speech-language therapy. Main Outcome Measures: Three subscales were drawn from 2 standardized measures of behavioral and social functioning, the Behavioral Assessment Scale for Children (Adaptability, Social Skills) and the Social Skills Rating System (Social Skills). A latent social competence variable was created using multiple subscales, which was modeled over time. Results: Parent data indicated that children with CIs were delayed in comparison to their hearing peers on the social competence latent variable across all time points. Further, there was minimal evidence of ‘‘catch-up’’ growth over this 5-year period. Conclusion: Children with CIs continued to experience delays in social competence after several years of implant use. Despite documented gains in oral language, deficits in social competence remained. To date, no interventions for children with CIs have targeted these social and behavioral skills. Thus, interventions that address the functioning of the ‘‘whole child’’ following cochlear implantation are needed. Key Words: Cochlear implants—Parent ratings— Social competence—Social skills.

Emotional and behavioural difficulties in children and adolescents with hearing impairment: a systematic review and meta-analysis

Article

Full-text available

Mar 2015
EUR CHILD ADOLES PSY

The aim of this study is to estimate the extent to which children and adolescents with hearing impairment (HI)show higher rates of emotional and behavioural difficulties compared to normally hearing children. Studies of emotional and behavioural difficulties in children and adolescents were traced from computerized systematic searches supplemented,where appropriate, by studies referenced in previous narrative reviews. Effect sizes (Hedges’ g) were calculated for all studies. Meta-analyses were conducted on the weighted effect sizes obtained for studies adopting the Strength and Difficulties Questionnaire (SDQ) and on the unweighted effect sizes for non-SDQ studies. 33 non-SDQ studies were identified in which emotional and behavioural difficulties in children with HI could be compared to normally hearing children. The unweighted average g for these studies was 0.36. The metaanalysis of the 12 SDQ studies gave estimated effect sizes of 0.23 (95 % CI 0.07, 0.40), 0.34 (95 % CI 0.19, 0.49) and −0.01 (95 % CI −0.32, 0.13) for Parent, Teacher and Selfratings of Total Difficulties, respectively. The SDQ sub-scale showing consistent differences across raters between groups with HI and those with normal hearing was Peer Problems. Children and adolescents with HI have scores on emotional and behavioural difficulties measures about a quarter to a third of a standard deviation higher than hearing children. Children and adolescents with HI are in need of support to help their social relationships particularly with their peers.

Comparisons of Social Competence in Young Children With and Without Hearing Loss: A Dynamic Systems Framework

Article

Full-text available

Dec 2014

This study compared levels of social competence and language development in 74 young children with hearing loss and 38 hearing peers, age: 2.5-5.3 years. This study was the first to examine the relationship between oral language and social competence using a dynamic systems framework in children with and without hearing loss. We hypothesized that, due to deficits in oral language, children who were deaf would display lower levels of social competence than their hearing peers. Furthermore, language age would predict social competence scores. Social competence was measured using a general and deaf-specific measure. Results showed that children with hearing loss performed significantly worse than hearing peers on the general measure, but better than the norms on the deaf-specific measure. Controlling for maternal education and income, regression analyses indicated that hearing status and language age predicted social competence in both groups. Among children with hearing loss, correlations were also found between age at diagnosis, age at amplification, and two of the general social competence measures. Results supported our hypothesis that deficits in language would have cascading negative effects on the development of social competence in young, deaf children. Development of early intervention programs that target both language and social skills are needed for this population. © The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Speech Intelligibility in Deaf Children After Long-Term Cochlear Implant Use

Article

Full-text available

Dec 2014

Purpose: This study investigated long-term speech intelligibility outcomes in 63 prelingually deaf children, adolescents, and young adults who received cochlear implants (CIs) before age 7 (mean=2;11, range=0;8-6;3) and used their implants for at least 7 years (mean=12;1, range=7;0-22;5). Method: Speech intelligibility was assessed using playback methods with naïve, normal-hearing listeners. Results: Mean intelligibility scores were lower than scores obtained from an age- and non-verbal-IQ matched normal-hearing control sample, although the majority of CI users scored within the range of the control sample. Our sample allowed us to investigate the contribution of several demographic and cognitive factors to speech intelligibility. CI users who used their implant for longer periods of time exhibited poorer speech intelligibility scores. Crucially, results from a hierarchical regression model suggested that this difference was due to more conservative candidacy criteria in CI users with more years of use. No other demographic variables accounted for significant variance in speech intelligibility scores beyond age of implantation and amount of spoken language experience (assessed by communication mode and family income measures). Conclusions: Many factors that have been found to contribute to individual differences in language outcomes in normal-hearing children also contribute to long-term CI users’ ability to produce intelligible speech.

Children Who Are Deaf or Hard of Hearing in Inclusive Educational Settings: A Literature Review on Interactions With Peers

Article

Full-text available

Jul 2014

This review is conducted to describe how children who are deaf or hard of hearing (D/HH) interact with hearing peers in inclusive settings, illustrate the difficulties and challenges faced by them in interacting with peers, and identify effective interventions that promote their social interaction in inclusive education. A systematic search of databases and journals identified 21 papers that met the inclusion criteria. Two broad themes emerged from an analysis of the literatures, which included processes and outcomes of interactions with peers and intervention programs. The research indicates that children who are D/HH face great difficulties in communicating, initiating/entering, and maintaining interactions with hearing peers in inclusive settings. The co-enrollment and social skills training programs are considered to be effective interventions for their social interaction. Communication abilities and social skills of children who are D/HH, responses of children with normal hearing, and the effect of environment are highlighted as crucial aspects of social interactions. In addition, future research is needed to study the interaction between children who are D/HH and hearing peers in natural settings, at different stages of school life, as well as improving social interaction and establishing an inclusive classroom climate for children who are D/HH.

Executive Functioning Skills in Preschool-Age Children With Cochlear Implants

Article

Full-text available

Feb 2014
J SPEECH LANG HEAR R

Purpose: The purpose of this study was to determine whether deficits in executive functioning (EF) in children with cochlear implants (CIs) emerge as early as the preschool years. Method: Two groups of children ages 3 to 6 years participated in this cross-sectional study: 24 preschoolers who had CIs prior to 36 months of age and 21 preschoolers with normal hearing (NH). All were tested on normed measures of working memory, inhibition-concentration, and organization-integration. Parents completed a normed rating scale of problem behaviors related to EF. Comparisons of EF skills of children with CIs were made to peers with NH and to published nationally representative norms. Results: Preschoolers with CIs showed significantly poorer performance on inhibition-concentration and working memory compared with peers with NH and with national norms. No group differences were found in visual memory or organization-integration. When data were controlled for language, differences in performance measures of EF remained, whereas differences in parent-reported problems with EF were no longer significant. Hearing history was generally unrelated to EF. Conclusions: This is the first study to demonstrate that EF deficits found in older children with CIs begin to emerge as early as preschool years. The ability to detect these deficits early has important implications for early intervention and habilitation after cochlear implantation.

Behavior Assessment System for Children, Second Edition (BASC‐2)

Chapter

Jan 2015

Randy W. Kamphaus

The Behavior Assessment System for Children, Second Edition ( BASC ‐2), is indeed a system, in that it includes a wide range of measures and scales designed for the comprehensive assessment of child behavioral and emotional adjustment, mental health, subsyndromal mental health symptoms, and behavioral and emotional competencies. The system includes the widely used teacher, parent, and student self‐report ratings scale, as well as college and early elementary grade self‐report forms, progress monitoring forms, clinician and classroom intervention guides, the Parenting Relationship Questionnaire, a developmental history form, the Student Observation Scale for classroom observations, the Behavioral and Emotional Screening System, and other supplementary materials. Information about the administration, scoring, interpretation, and reliability and validity evidence related to the core BASC ‐2 rating scales is presented.

The differential ability scales

Article

Jan 2007

C.D. Elliott

Early identification: Language skills and social functioning in deaf and hard of hearing preschool children

Article

Oct 2015

Objective: Permanent childhood hearing impairment often results in speech and language problems that are already apparent in early childhood. Past studies show a clear link between language skills and the child's social-emotional functioning. The aim of this study was to examine the level of language and communication skills after the introduction of early identification services and their relation with social functioning and behavioral problems in deaf and hard of hearing children. Study design: Nationwide cross-sectional observation of a cohort of 85 early identified deaf and hard of hearing preschool children (aged 30-66 months). Methods: Parents reported on their child's communicative abilities (MacArthur-Bates Communicative Development Inventory III), social functioning and appearance of behavioral problems (Strengths and Difficulties Questionnaire). Receptive and expressive language skills were measured using the Reynell Developmental Language Scale and the Schlichting Expressive Language Test, derived from the child's medical records. Results: Language and communicative abilities of early identified deaf and hard of hearing children are not on a par with hearing peers. Compared to normative scores from hearing children, parents of deaf and hard of hearing children reported lower social functioning and more behavioral problems. Higher communicative abilities were related to better social functioning and less behavioral problems. No relation was found between the degree of hearing loss, age at amplification, uni- or bilateral amplification, mode of communication and social functioning and behavioral problems. Conclusion: These results suggest that improving the communicative abilities of deaf and hard of hearing children could improve their social-emotional functioning.

Factors Affecting Psychosocial and Motor Development in 3-Year-Old Children Who Are Deaf or Hard of Hearing

Article

Jul 2015
J DEAF STUD DEAF EDU

Previous research has shown an association between children's development of psychosocial and motor skills. This study evaluated the development of these skills in 301 three-year-old deaf and hard of hearing children (M: 37.8 months) and considered a range of possible predictors including gender, birth weight, age at first fitting with hearing devices, hearing device used, presence of additional disabilities, severity of hearing loss, maternal education, socio-economic status (SES), language ability, and communication mode. Caregivers reported on children's development using the Child Development Inventory (CDI). On average, both psychosocial and motor development quotients were within the typical range for hearing children, with large individual differences. There was a positive correlation between language ability and both social and motor development, and also between social and motor development. Age at first fitting of hearing aids (as an indicator of age at identification of hearing loss), SES, degree of hearing loss, and maternal education were not significant predictors of social skill or motor development, whereas presence of additional disabilities and birth weight were. Girls performed better than boys on all but the Gross Motor subscale of the CDI. Children with hearing aids tended to perform better than those with cochlear implants on the Gross Motor subscale. © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Speech Intelligibility and Psychosocial Functioning in Deaf Children and Teens with Cochlear Implants

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