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Embodied cognition in prelingually deaf children with cochlear implants: Preliminary findings



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Embodied Cognition in Prelingually Deaf Children with Cochlear Implants:
Preliminary Findings
Irina Castellanos
Department of Otolaryngology – Head & Neck Surgery
The Ohio State University
David B. Pisoni
Department of Psychological and Brain Sciences
Indiana University
Chen Yu
Department of Psychological and Brain Sciences
Indiana University
Chi–hsin Chen
Department of Otolaryngology – Head & Neck Surgery
The Ohio State University
Derek M. Houston
Department of Otolaryngology – Head & Neck Surgery
The Ohio State University
Correspondence to:
Irina Castellanos, Ph.D.
Department of Otolaryngology – Head & Neck Surgery
The Ohio State University
915 Olentangy River Rd
Columbus, Ohio 43212
This research was supported by grants from the National Institute on Deafness and
Other Communication Disorders (T32 DC00012), the National Institute of Child Health and
Human Development (R01 HD074601), and the Indiana University Collaborative Research
The theory of embodiment postulates that cognition emerges from multisensory
interactions of an agent with its environment and as a result of multiple overlapping and
time–locked sensory–motor activities. In this chapter, we discuss the complex multisensory
system that may underlie young children’s novel word learning, how embodied attention may
provide new insights into language learning after prelingual hearing loss, and how embodied
attention may underlie learning in the classroom. We present new behavioral data
demonstrating the coordination of sensory–motor behaviors in groups of young children with
prelingual hearing loss (deaf, early–implanted children with cochlear implants and hard–of–
hearing children with hearing aids) and without hearing loss (two control groups of
chronological–aged and hearing–aged matched peers). Our preliminary findings suggest that
individual differences and variability in language outcomes may be traced to children’s
coordination of auditory, visual, and motor behaviors with a social partner.
Keywords: Cochlear Implants, Embodied Cognition, Multisensory Processing, Eye
Tracking, Mother–Infant Dyads, Novel Word Learning
Embodied Cognition in Prelingually Deaf Children with Cochlear Implants:
Preliminary Findings
Cochlear implants (CIs) provide access to sound for many deaf children with severe–
to–profound sensorineural hearing loss. CIs represent a significant engineering and medical
milestone in the treatment of sensorineural hearing loss. Unfortunately, while many CI
candidates display substantial benefits in recognizing speech and processing spoken language
following implantation, a significant number of children have poor outcomes and often
display less than optimal speech and language skills following implantation even after several
years of experience with their CIs. The estimates of poor outcomes following cochlear
implantation range between 25 to 30 percent, depending on what behavioral criteria are used
to assess benefit and outcomes. Most CI users get some benefit from their implant in quiet
listening conditions such as in the audiology clinic or research laboratory, although they
commonly report significant difficulties in listening to speech in the presence of background
noise, especially when multi–talkers are present, or listening to speech under conditions of
high cognitive and attentional load.
The problem in understanding and explaining the underlying basis of poor speech–
language outcomes, including language acquisition, following cochlear implantation is a very
challenging research issue that has not received sufficient attention in the literature despite
the pressing clinical significance. Why do some CI users do extremely well in the quiet and
why do others struggle and very often fail to reach optimal levels of speech recognition
performance even under ideal listening conditions in the clinic or laboratory? This question
represents a significant gap in our current knowledge concerning outcomes following
cochlear implantation and is an important barrier to progress in developing novel and
personalized interventions to help low–functioning CI users improve their speech–language
outcomes. Part of the difficulty with speech recognition stems from the nature of the signal
CI users receive through their implant which is spectrally–degraded and significantly
compromised relative to the original signal presented at the ear. The critical acoustic–
phonetic cues in the signal that support speech recognition are coarsely–coded and the fine
acoustic–phonetic and indexical details of the original speech are significantly reduced or
often absent from the neural encoding presented to the auditory nerve and higher information
processing centers. While some of the minimal acoustic–phonetic cues needed for speech
recognition are preserved in CIs in coarsely–coded form, the critical speech cues are
generally underspecified by the signal processing algorithms currently available for clinical
Several researchers are looking beyond the endpoint or product–based outcome
measures traditionally used to assess performance following implantation and are focusing
their efforts on identifying and explaining sources of individual variability and the underlying
processes that may lead to them (e.g., Markman et al., 2011; Moeller, 2007). Similarly, we
propose that a broader, developmental systems approach should be adopted using process–
based measures that allow for the discovery of both macrostructural and microstructural
developmental change. Developmental change is not an isolated process, but instead arises
from interactions across coordinated sensory and cognitive systems. For example, the
variability observed in conventional speech–language outcome measures not only reflects the
early sensory registration and encoding of acoustic signals by the auditory nerve, but it also
reflects the important and central contribution of the information processing system as a
whole. The information processing system involves cognitive processing factors and
contributions such as selective and sustained attention, sustained sequential processing, and
inhibitory control, which are actively used by listeners to support encoding, processing,
storage and retrieval of information (see Kronenberger & Pisoni, this volume). Speech
scientists and acoustical engineers have known for more than 60 years that speech
recognition and spoken language processing do not take place at the auditory periphery in the
ear. Robust spoken word recognition and speech understanding reflects the final product of a
long series of stages of information processing that routinely draw on multiple resources and
the interactions of different sources of knowledge in long–term memory that are based on the
listener’s prior experiences and unique developmental histories.
In this chapter, we adopt a developmental systems approach to the study of novel
word learning in prelingually deaf and hard–of –hearing children (D/HH). We summarize
recent findings on a feasibility study using novel eye tracking process–based measures to
examine how D/HH children with cochlear implants and hearing aids (HAs) coordinate
sensory–motor behaviors during naturalistic joint play with a social partner and we contrast
these findings with data collected from two control groups of normal hearing (NH) children.
Lastly, we suggest methods for how knowledge about embodied attention may translate into
novel interventions to support children’s learning in the classroom.
<1>Embodied Cognition and Joint Attention
One of the overarching questions in the field of cognitive development in children
concerns how selective attention is organized during early development to facilitate the
mapping of a word to a referent (novel word learning). During early development, word
learning results from complex parent–child interactions involving joint attention. Parent–
child joint attention occurs when the parent and child coordinate visual attention on the same
object or event at the same time (Moore & Dunham, 1995). Embodied cognition provides an
approach for describing and examining multiple pathways to the coordination of joint visual
attention. Children may utilize their own sensory–motor skills, parental linguistic input and
social cues to coordinate joint attention in the service of word learning. Consequently, novel
word learning may be viewed as grounded and emerging from multisensory interactions
between the child and his/her social–cultural environment and as a result of multiple
overlapping and time–locked sensory–motor activities. Yu & Smith (2013) have described
how visual and motor movements are spatially and temporally coupled during goal–directed
actions, thereby redundantly specifying information about the agent’s locus of attention. In
fact, young NH children make use of information garnered from watching their parent’s
motor movements to engage in joint attention with their parent.
Engaging in joint visual attention is not accidental; instead, it relies on a foundation of
multisensory functioning (coordinating visual, linguistic, and motor cues) with the goal of
sharing a social experience/interest. The child may respond to episodes of joint attention by
following a parent’s gaze shifts to, touching/holding, or labeling of objects in the
environment or the child may initiate episodes of joint attention with a caregiver or peer.
Delays and/or disturbances in children responding to or initiating joint attention with a social
partner may have cascading effects on neurocognitive development, particularly language
Skilled parent–child coordination is a product of a complex system, with multiple
degrees of freedom, relying on multiple solutions to the in–moment tasks of coordinating
attention and behavior. For example, 18–month–old toddlers with normal hearing use their
hand actions to select visual objects during mother–child play interactions, and parents’
notice and use toddlers’ actions on objects as behavioral cues to label objects for toddlers (Yu
& Smith, 2012). This time–locked sequential pattern, from child manual handling to parent
labeling, suggests an interpersonal coordination that jointly solves the referential uncertainty
problem in early word learning –– finding correct word referent mappings among many co
occurring words and referents.
Tomasello and colleagues’ seminal work investigated macrostructural and
microstructural changes in mother–child dyadic interactions during naturalistic play
(Tomasello & Farrar, 1986; Tomasello, Mannle, & Kruger, 1986; Tomasello & Todd, 1983).
The dyad was video recorded playing with novel toys supplied by the experimenters and no
specific instructions were provided about how to engage with the toys (classic joint attention
task). At the macrostructural level, they quantified the amount of mother–child joint attention
episodes that occurred during play. At the microstructural level, they described the verbal and
nonverbal behaviors of the mother–child dyad within episodes of joint attention. Several
interesting findings were uncovered indicating that measures of joint attention may predict
children’s language knowledge.
For example, at the macrostructural level, Spencer, Meadow–Orlans, Koester, &
Ludwig (2004) examined how the quality of mother–child interactions at age 12 months
affect deaf and NH children’s language learning at age 18 months. The data revealed
associations between the amount of time the parent–child dyad engaged in joint attention and
later language learning for both the deaf and hearing children. Similarly, Tomasello & Todd
(1983) found the amount of time NH parent–child dyads jointly attended to novel toys was
related to children’s vocabulary size six months later.
Tomasello & Todd (1983) suggest that children’s novel word learning may in part
depend on parents’ attunement or skills at determining and following the child’s attentional
focus. Parents may facilitate episodes of joint attention by providing a label for an object
already in the child’s attentional focus or may regulate episodes of joint attention by
redirecting the child’s attentional focus to labeled objects. Observational studies suggest that
object labels provided by parents while following their NH child’s attentional focus
facilitated joint attention and larger vocabulary sizes (Tomasello & Farrar, 1986).
Experimental studies that systematically manipulated how labels for objects are presented
suggest that NH children learn novel words for objects more easily when the labels are
presented in an attempt to follow the child’s attentional focus instead of when the labels are
presented in an attempt to redirect the child’s attentional focus from one object to another
(Dunham, Dunham, & Curwin, 1993; Tomasello & Farrar, 1986).
Several factors may influence the ease of coordinating joint attention between parent
and child, one of which may be a shared sensory history. Mother–child dyads who share
hearing status (deaf mother with deaf child; NH mother with NH child) spend more time in
joint attention than mother–child dyads that do not share hearing status (deaf mother with NH
child; NH mother with deaf child; Spencer, Swisher, & Waxman, 2004).
At the microstructural level, Tomasello et al. (1986) found that parents’ use of verbal
and nonverbal actions to direct NH children’s visual attention and behavior was negatively
correlated with shorter episodes of mother–child joint attention and less knowledge of
object–word pairings, suggesting that highly directive parental styles are not conducive to
early language learning in NH children. Research also indicates that NH mothers of deaf
children engage in higher levels of directive parental styles, which result in lesser gains in
language growth (Musselman & Churchill, 1992). Highly directive parental styles may also
influence the kind of language children use. Parents who employ highly directive styles often
have NH children with predominately expressive, rather than referential, language
(Tomasello & Todd, 1983). Moreover, case studies suggest that NH children with
predominately referential language hear more maternal talk about objects, have more labels
for objects, and initiate episodes of joint attentional focus more often than children with
predominately expressive language (Goldfield, 1986).
Cejas, Barker, Quittner, & Niparko (2014) have further differentiated between joint
attention with and without accompanying parental symbols. The authors investigated parent–
child joint attention in a group of prelingually deaf CI candidates (tested prior to
implantation) and NH peers aged 0.75 – 5.09 years. All participating parents were hearing
and children were divided into three age groups: under 18 months, 18–36 months, and over
36 months. The parent–child dyads were asked to play with age–appropriate toys and their
behaviors were coded for engagement. Parental symbols were categorized as verbal (spoken
language) or nonverbal (sign language). Child use of symbolic play was coded, as well as,
their looking behaviors (looking toward parent, object, or both). If children were actively
attending to symbols (e.g., verbal or nonverbal parental gestures or engaged in symbolic
play) while maintaining joint attention with a parent they were coded as engaged in “symbol–
infused” joint attention. This differs from parent–child joint attention without accompanying
parental symbols.
The authors found no differences in joint attention versus “symbol–infused” joint
attention between deaf and NH children aged under 18 months. In the two older age groups,
however, CI candidates spent less time engaged in “symbol–infused” joint attention with
their hearing parent when compared against hearing children with their hearing parents.
Additionally, CI candidates spent more time engaged in joint attention (without any
accompanying parental symbols), than their NH peers. These results are similar to those
reported in an earlier study by Prezbindowski, Adamson, & Lederberg (1998), indicating that
deaf children engaged in more joint attention, but less “symbol–infused” joint attention with
their NH parents when compared to NH parent–NH child dyads.
Taken together, these studies suggest that joint attention scaffolds children’s attention
and promotes the acquisition of words for objects. Episodes of joint attention are influenced
by a number of endogenous and exogenous factors such as matched sensory history (hearing
or deafness), parenting style (redirecting attentional focus versus following attentional focus),
and linguistic input (directives). Dyads consisting of a NH mother and a deaf child are at a
disadvantage when engaging in joint attention because they are unable to rely on linguistic
input to direct or maintain episodes of joint attention. Several interesting questions follow
from these findings, for example: Is it possible that NH parents are so attuned to their child’s
profound–to–severe hearing loss that they fully rely on visual attention before the child’s
cochlear implantation/hearing aid amplification? Does dyadic engagement in more advanced
“symbol–infused” joint attention episodes increase following cochlear implantation? How are
visual, auditory, and motor behaviors spatially and temporally coupled during episodes of
parent–child joint attention when the child has a hearing loss? To study these questions and
many others related to macrostructural and microstructural change, in the following section,
we introduce a new multisensory eye tracking methodology that provides multiple streams of
high–density frame–by–frame recordings, allowing us to identify the potential multiple
pathways through which children (with and without hearing loss) align their attention with a
social partner. Multiple pathways involving visual, auditory, and motor skills are
hypothesized to regulate the coordination of joint attention skills that are critically important
for the development of novel word learning.
<1>Multisensory Language Learning
Recently we began a collaborative research project involving the Departments of
Otolaryngology–Head & Neck Surgery, Psychological and Brain Sciences, and Informatics
and Computing to employ a multisensory experimental methodology to investigate parents
and D/HH children’s reciprocal roles in language acquisition and cognitive development.
Specifically, we sought to investigate how D/HH children’s multisensory (auditory, visual,
and motor) functions lead to learning of novel words for toy objects during joint play
activities with their parents. The ongoing goal of this research program is to achieve a deeper
and more detailed understanding of the sensory–motor basis of early social coordination and
its potentially critical role in later language learning and other development milestones.
The premise for the experiment is quite simple: the parent–child dyad is presented
with novel toy objects and asked to engage in play. Up to this point, our experimental
methodology is very similar to the traditional studies examining novel word learning
described earlier in this chapter. We depart from previous studies examining deaf children’s
word learning with our use of sophisticated computer vision technology. The use of our
state–of–the–art sensing and computing technology allows us to collect process–based
measures (instead of only endpoint measures of word learning) of real–time microstructural
change in how the mother–child dyad arrives at joint attention and, if word–referent learning
occurs, we can pinpoint with frame–by–frame precision the visual, linguistic, or sensory–
motor cues that facilitated learning.
In our experiment, the child and parent wear small head–mounted cameras and eye
trackers throughout the joint play session so that precise time–locked measures of what they
are looking at and what they are touching can be obtained. Before the development of these
novel research methods, it was not possible to measure the fine temporal dynamics of parent–
child interactions with this level of detail and precision. These new research methods allow
us to collect fine–grained multimodal behavioral data from young children with time
synchronized eye gaze, action, and speech data.
The experimental setup requires that the testing room (walls, floors, and play
furniture) be outfitted in white. The dyads are provided with white clothing (long sleeve
shirts, pants, and socks), as well. The all–white experimental room is necessary so that the
novel play toys (painted in primary colors: red, green, and blue) can be easily detected and
extracted from the background by our computer vision algorithm. Employing computer
vision technology, a three–step segmentation algorithm was designed to automatically
identify the toy object and output its precise size and location in space (for detailed
information, see Yu, Smith, & Pereira, 2008). With this information, we can make statements
about how much space an object occupies in a child’s visual field (e.g., object “Mobit”
occupies 80% of the space in the child’s visual field and is visually dominant over the other
objects), and test specific hypotheses about how visual and motor behaviors are coordinated.
––– Insert Figure 1 About Here –––
Once dressed in white clothing, the dyad is led into the all–white experimental room
which contains a white play table. On opposite sides of the play table, a white chair is
available for the child and a white floor cushion is available for the parent. The child’s
custom chair measures 32 cm above the floor, which allows the child to be approximately
eye–to–eye with their parent when the parent is seated on the floor. The child wears a cotton
cap with the lightweight head–mounted camera and eye tracker securely attached (see Figure
1, Panel A), while the parents’ equipment is mounted onto frameless glasses. The play
session is also audio–recorded using microphones integrated into the parent and child’s eye
tracking equipment. The majority of the weight of the eye tracking equipment is placed on
the back of the chair (for the child) or on the floor (for the parent). We have tested this eye
tracking equipment on children before and after cochlear implantation, children with HAs,
and with Bone Anchored Hearing Aids (BAHAs), and have not had any device issues or
electrical interference. Additionally, a bird’s eye view camera is positioned above the play
session and two scene cameras are positioned on opposite corners of the room. These
recording devices allow us to obtain multiple streams of high–density frame–by–frame gaze,
action, and speech data throughout the free–flowing interactive play session.
At the beginning of the testing session, an experimenter calibrates the position of the
head–mounted camera and the angle of the eye tracker relative to the child’s head. A similar
calibration procedure is performed for the parent head–mounted camera and eye tracker. A
secondary experimenter controls the recording of all cameras and recommends adjustments to
the positioning of cameras when necessary. After the calibration phase, the parent–child dyad
is free to engage to play.
The dyad is presented with two sets of toys that are similar in size, with each set
containing three novel objects paired with three novel labels. Each set is presented twice for a
total of four 90–second trials. Each novel toy is a complex nonsense object, and many have
functional parts (e.g., wheels). Parents are asked to play with their children as they normally
would at home. However, if they are going to refer to the toy objects by name, we ask the
parents to refer to toy objects by their novel labels. The parent is not tasked with
remembering the object–word pairings; in fact, a cheat–sheet is attached to their side of the
table for easy reference (see Figure 1, Panel B). Object labels follow a consonant–vowel–
consonant–vowel structure, which can be easily said by the parent, and can be easily heard by
the child.
Immediately following the parent–child play session, children’s novel word learning
is assessed using the intermodal preferential looking paradigm (IPLP). In the IPLP, two
objects are presented side–by–side, but only one of the objects corresponds to an
accompanying linguistic label (referred hereafter as the target object; Golinkoff, Hirsh–
Pasek, Cauley & Gordon, 1987). The IPLP contains three training trials and twelve test trials.
During each training trial, two familiar objects are presented, a target and a nontarget, side–
by–side and the child is asked, “Where is the (target object)? Can you find the (target
object)?” Familiar objects (bear, car, banana, cow, horse, fork) were selected from highly
familiar words that appear on the MacArthur–Bates CDI Words and Gestures list (Fenson et
al., 2007). If the child incorrectly identifies the incorrect (nontarget) object, the experimenter
corrects the response by redirecting the child towards to target object. Test trials commence if
the child demonstrates competence with the task by correctly identifying all three target
objects during the training trials. During test trials, the experimenter presents the play session
objects two at a time, and again asks the child, “Where’s the (target object)? Can you find the
(target object)?” After each test trial the experimenter praises the child for selecting a toy,
but no corrections are provided. Each novel toy object serves twice as the target (six novel
toy objects presented across twelve test trials). The order in which the toy objects are
presented and the lateral position of the target object is counterbalanced.
Following data collection, the parent and child’s gaze (e.g., where and what the parent/child
is looking at, how much space does an object occupy in the parent/child’s visual field) and
motor (e.g., what toy is the parent/child holding in their left and right hand) data are coded
frame–by–frame, coupled together with the speech transcription, and analyzed for patterns of
dyadic synchronization. Audio recordings from the parent and child during the play session
are first transcribed using Systematic Analysis of Language Transcripts (SALT) transcription
conventions. These transcriptions are then used to identify the number of topics discussed per
utterance. A topic refers to a label that is correctly provided for an object. Adjacent utterances
containing pronouns referring to the labeled object are considered a topic expansion. The
following is an example of two utterances on one topic: Mother: “Is that a Zeebee? What will
you do with it?” And an example of two utterances with two topics: Mother: “Is it a Dodi? Is
that the Zeebee?” Finally, transcriptions from the play session are used to classify utterances
as declarative, open–ended questions, directives, or other.
<2>Feasibility Study
A feasibility study was conducted to examine if D/HH children with CIs/HAs display
differences in visual skills (gaze duration, gaze shifting), motor skills (duration and frequency
of object holding), and linguistic input (numbers of utterances and topics, utterance forms)
during joint play interactions with their parents. Additionally, we sought to determine the
viability of using an embodied eye tracking system with D/HH children who received
different forms of audiological hearing intervention (CIs and HAs). The long–term goal of
this project is to identify the underlying processes that regulate and contribute to individual
differences in joint attention skills and novel word learning before and after audiological
hearing intervention.
Five D/HH children (three with CIs and two with HAs) were recruited from a large
university hospital–based speech and hearing clinic and local advertisements. CI and HA
users were required to have used their hearing device for 10 months or more, use a currently
available state–of–the–art hearing device, live in a home with spoken English as the primary
language, and have no additional developmental, neurological, or cognitive conditions other
than hearing loss. Demographics and hearing history variables obtained for the D/HH sample
are provided in Table 1. Etiology of hearing loss included unknown (N = 4, 80%) and
congenital (N = 1, 20%). Participants in the D/HH sample averaged 32.80 (4.21) months old
at time of testing with 16.60 (6.54) months of device use. At time of testing, all children
reported using oral communication strategies.
Participants in the NH control sample were 10 children who reported no significant
developmental, neurological, or cognitive delays. NH peers were recruited from
advertisements placed in the community. Characteristics of the NH sample are also
summarized in Table 1. Five NH participants were recruited as chronological–age matched
controls and averaged 31.40 (5.86) months old at time of testing. An additional five NH
participants were recruited as hearing–age matched controls and averaged 17.20 (5.77)
months old at testing. Two NH control samples were necessary to disentangle effects of age
from effects of access to sound. All D/HH and NH children participated in this feasibility
study with their NH mothers.
––– Insert Table 1 About Here –––
Study procedures were followed as described above, except because of the large
amount of individual variability and our small sample size, children’s novel word learning
results are omitted. Figure 2 depicts a comparison between one deaf child with CIs (top
panel) and their NH chronological–age matched peer (bottom panel). This figure shows the
duration of each novel object (represented in the three primary colors: red, green, blue) and
face (represented in pink) in the child’s and mother’s visual field over the course of 30
seconds, respectively. Figure 2 (top panel) provides evidence of decoupling between what the
child and mother viewed. However, there are also several episodes in time where there is
clear visual evidence of the mother–child dyad jointly attending to the same object at the
same time (bottom panel).
––– Insert Figure 2 About Here –––
Children’s ability to deploy selective attention and maintain sustained attention is a
hallmark of self–regulation (Ruff & Rothbart, 2001), is influenced by joint play with a social
partner (Yu & Smith, 2016), and is highly predictive of later executive functioning skills
(Barkley, 1997). As such, we examined the effect of hearing status and age on gaze duration
and gaze shifting. Gaze data were analyzed with respect to four regions of interest (ROIs):
each of the three novel toys and the face. Children’s gaze duration to the ROIs was equivalent
across hearing status and age; however, the frequency of gaze shifting across ROIs was
significantly different (F(2, 12) = 6.381, p < .05; see Figure 3, Panel A and B respectively).
D/HH children shifted gaze across ROIs (18.47 switches per minute) more often than their
NH chronological–age (11.12 shifts per minute) and hearing–age (8.94 shifts per minute)
matched peers. Is increased gaze shifting indicative of CI/HA users’ increased perceptual
flexibility or an inability to use linguistic information to constrain and sustain visual
attention? The latter interpretation is in line with previous research indicating that preschool
CI users are at high risk for delays in executive functioning, namely, attention and sustained
sequential processing skills (Kronenberger, Beer, Castellanos, Pisoni, & Miyamoto, 2014).
Analyses were also conducted to determine if hearing status and age influenced
children’s and parent’s toy manipulation during joint play. There were no differences across
hearing status or age in children’s duration or frequency of object holding. NH parents’
duration and frequency of object holding also did not differ as a function of their child’s
hearing status or age.
––– Insert Figure 3 About Here –––
With respect to linguistic input, there were no differences in mothers’ total number of
utterances and the total number of topics discussed. However, differences across children’s
hearing status began to emerge when mothers’ utterances were classified by form. NH
mothers of D/HH children were more likely to use words to describe object features (e.g.,
color, shape) than NH mothers of hearing–age matched peers. NH mothers of D/HH children
used more directives than NH mothers of chronological–age matched controls. NH mothers
of D/HH children and hearing–aged matched controls used similar amounts of directives,
suggesting that mother’s speech to D/HH children may be specially tailored by their child’s
hearing experience instead of their child’s chronological age. Previous studies have similarly
shown that NH mother tailor their infant–directed speech according to CI users’ hearing age
(Bergeson, Miller, & McCune, 2006). Alternatively, mother’s use of more directives may
suggest that mothers in this study needed to exert more control over D/HH children’s
physical behavior. NH mothers of NH chronological–age and hearing–age matched children
used more open–ended questions than NH mothers of D/HH children. This finding is
particularly interesting given the work by DesJardin and colleagues suggesting that parent’s
use of open–ended questions is positively associated with growth in expressive language
skills in pediatric CI users (Cruz, Quittner, Marker, & DesJardin, 2013; DesJardin &
Eisenberg, 2007).
With only 15 mother–child dyads, our preliminary findings demonstrate the feasibility
of collecting real–time eye tracking data with young D/HH children who use CIs and HAs.
Although we are only beginning to scratch the surface, using this multisensory eye tracking
system we are able to mine the frame–by–frame data for patterns of dyadic synchronization.
We are also able to examine differences across individual mother–child dyads, as well as,
within episodes of joint attention.
<1>Embodied Cognition in the Classroom
“In the normal environment there is always more information than the organism is
capable of registering. There is a limit to the attentive powers of even the best
educated human perceiver” (Gibson, 1969, p. 75).
Neurobiological research on the visual cortex indicates that the brain is unable to
process all the visual information (108–109 bits per second) entering the retina (Deco,
Pollatos, & Sihl, 2002). Since all properties of our multimodal environment cannot be
encoded and processed simultaneously, attention is allocated to some properties while others
are ignored. This information processing bottleneck has a great influence on deaf children
with CIs, who have to rely on highly degraded auditory information and often report being
mentally exhausted by the richness of the multimodal environment. As discussed by
Marschark & Leigh (2016), educators need to acknowledge that numerous factors, including
hearing and neurocognitive abilities, influence deaf children’s learning and academic
performance in the classroom. In this final section, we focus on strategies for how educators
may reduce uncertainty and ambiguity in the learning environment in order to support the
development of deaf children’s focused attention and inhibition–concentration skills.
In terms of neurocognitive abilities, our eye tracking data, presented in the previous
section, suggests that when interacting with parents during play, D/HH toddlers who use
CIs/HAs display more gaze shifting per minute, a potential early behavioral manifestation of
distractibility. Indeed, by preschool age, parent–reported data suggests that a larger portion of
CI users are at risk for clinical delays in controlled and automatic attention when compared to
their NH peers (Kronenberger et al., 2014). Parents also report that preschool children with
CIs have greater difficulty with working memory and inhibiting prepotent behaviors (Beer,
Kronenberger, Castellanos, Colson, Henning & Pisoni, 2014). Performance–based data
corroborates these findings in preschool and school age CI users. On a nonverbal visual task
measuring inhibition and concentration skills that required participants to identify and
eliminate target items from a larger display of items, preschool CI users performed
significantly poorer than their NH peers (Beer et al., 2014). Similarly, Castellanos et al.
(2015) reports that when compared to a sample of NH peers matched on nonverbal
intelligence, school age CI users performed significantly poorer on tasks measuring
inhibition–concentration: the Test of Variables of Attention (TOVA; Leark, Dupuy,
Greenberg, Corman, & Kindschi, 1996) and the Trail–Making Test (Delis, Kaplan, &
Kramer, 2001). On the TOVA, participants were asked to press a button when presented with
a target stimulus (a square at the top of a screen) but not when presented with a distractor
stimulus (a square at the bottom of a screen). On the Trail–Making Test, participants were
asked to connect a series of numbers and letters on a page by drawing a line alternating
between numbers and letters (e.g., a line connecting the number 1 to the letter A). Results
from the TOVA demonstrated that school age CI users were significantly slower to respond,
failed to respond to a target more often, and responded inaccurately to a distractor more often
than their NH peers. CI users also performed more poorly on the Trail–Making Test than
their NH peers. Together, performance on these two inhibition–concentration tasks predicted
CI users’ conceptual knowledge and use of linguistic labels to specifyi size, color, shape, and
quantity, basic concepts that are necessary for the understanding of science and mathematics
(Castellanos et al., 2015).
Classroom learning environments are often cluttered with acoustic noise (multiple
talkers speaking at the same time in background noise that challenge listening), and visual
noise (large amounts of visually salient stimuli that challenge focused visual attention).
Classroom babble, internal classroom noise generated by peers, has been found to have
negative effects on NH children’s learning and academic performance. For example, Shield
& Dockrell, (2008) reported that higher amounts of classroom babble was associated with
NH children’s (aged 7 years on average) poorer performance on reading, writing, and
mathematics tests. Group learning activities and semicircular seating arrangements may
present challenges for reducing classroom babble. Another aspect to consider is that
determining the localization of sound sources during group activities may be difficult for
unilateral CI users. Dedicated use of personal frequency modulation (FM) systems to amplify
the foreground sound (teacher’s voice) while attenuating background noise would be one
strategy for reducing competing noise caused by classroom babble.
Fisher, Godwin, & Seltman (2014) describe how the visual environment of a typical
classroom can effect NH children’s attention and learning. Two classroom environments
were constructed to investigate the effect of visual distractions on children’s learning of
science concepts: one classroom contained visually salient stimuli such as wall decorations
(e.g., posters, student drawings) typically found in kindergarten classrooms, while the second
classroom was void of wall decorations. The data suggest that NH children instructed in
classrooms with visually salient wall decorations spent more time off task on environmental
distractions and displayed less learning than NH children instructed in classrooms void of
visual decorations. The visual noise available in the classroom (both in central and peripheral
visual field) may be far more stimulating for CI users than their NH peers. Dye, Hauser, &
Bavelier (2008) caution educators from constructing classroom–seating arrangements such
that deaf children are in the front of the classroom with their peers behind them, because it
may lead to deaf children becoming more distractible. Instead of altering classroom–seating
arrangements, one strategy for reducing visual noise may be to simply limit visual
decorations so as not to attract attention away from the primary learning tasks.
Acoustic and visual noises make deploying selective attention, maintaining sustained
attention, inhibiting prepotent responses, and responding to joint attention more difficult for
CI users. Group learning activities, which are typical in primary school settings, can make it
difficult for CI users to follow the flow of ideas and conversation. Frequent adult monitoring
of CI users’ attention during tasks, especially peer–to–peer and group tasks is paramount to
promoting learning and academic success. We suggest the need for the frequent assessment
of CI users’ joint attentional skills throughout early development and school entry. CI users’
joint attentional skills may be assessed during short play interactions with their parents, peers,
and teachers. Also, during one–to–one instruction, parents, speech language pathologists, and
educators should introduce novel words and concepts by following CI users’ attentional focus
instead of attempting to redirect attentional focus.
As suggested by Dye, Hauser, & Bavelier (2008), increased research efforts need to
be placed on delineating the optimal learning environments necessary to support the
instruction of deaf children. The majority of the research conducted on CI users, our research
included, is visually and acoustically sterile (e.g., occurring in the sound booth, a quiet room
with an experimenter, or in an all white room with no visual distractors). Therefore, there is a
pressing clinical and educational need for research to be conducted on CI users’ learning in
mock classrooms with peers or in naturalistic classroom environments under more adverse
and challenging conditions. We hope that the easy functionality of our eye tracking
equipment will allow us to do just that: to obtain multiple measures of real–time learning in
speech–language therapy sessions and in the classroom. Early knowledge about CI users’
basic learning strategies and skills during naturalistic interactions will help inform decisions
about assessment, intervention, and educational placement.
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Table 1
Participant Demographics and Hearing History
Hearing Status
Hard–of –Hearing
Normal Hearing
Age Match
Normal Hearing
M (SD)
Age at Test (mos.)
32.80 (4.21)
31.40 (5.86)
17.20 (5.77)
Duration of CI/HA use (mos.)
16.60 (6.54)
Count (% of Sample)
Hearing Device
Bilateral, Sequential CIs
1 (20%)
Unilateral CI
1 (20%)
CI and HA
1 (20%)
Bilateral HAs
1 (20%)
Unilateral HA
1 (20%)
Etiology of Hearing Loss
4 (80%)
1 (20%)
3 (60%)
3 (60%)
3 (60%)
2 (40%)
2 (40%)
2 (40%)
Note. CI = Cochlear Implant; HA = Hearing Aid
Figure 1
Panel A: Head–mounted camera and eye tracking system
Panel B: Example of two sets of novel toys
Note. (A): A head–mounted camera and an eye tracker are placed on the child (pictured) and
the mother in order to collect visual information from their egocentric views. (B): The
parent–child dyad is provided with two sets of novel toys. Each set contains three toys
painted in primary colors: red, green, and blue.
Figure 3
Panel A: Gaze Duration for Regions of Interest (ROIs: 3 novel toy objects, face)
Panel B: Gaze Switching across Region of Interests (ROIs: 3 novel toy objects, face)
Note. D/HH = Deaf or Hard–of–Hearing; NH CA = Normal Hearing Chronological–Age
Match; NH HA = Normal Hearing Hearing–Age Match
Figure 2
An example of the synchronization of gaze data across time
Note. The child’s and parent’s gaze data stream are presented in each panel on the vertical axis. Looking to the face is presented in
pink, while looking to the three novel objects is presented red, green, and blue. Thirty seconds of elapsed time appears on the
horizontal axis.
Child with Cochlear Implants
Child’s Gaze
Parent’s Gaze
Child with Normal Hearing
Child’s Gaze
Parent’s Gaze
Time 0 30s
Time 0 30s
... Many studies have demonstrated various benefits associated with treating severe-profound hearing loss in children with cochlear implantation. These include spoken language development (Geers, 2004), improved speech perception (Calmels et al., 2004), enhanced reading skills (Geers & Hayes, 2011), a better quality of life (Warner-Czyz et al., 2009), and improved cognitive abilities (AuBuchon et al., 2015a;Castellanos et al., 2018). However several factors have been shown to influence performance with a CI: (1) age at implantation (Kral, 2007); (2) binaural or monoaural CI (Litovsky & Gordon, 2016); (3) type of bilateral cochlear implantation surgery (e.g., simultaneous or sequential and the duration between sequential CI surgeries (Killan et al., 2019); (4) speech processing strategy (Hu et al., 2011); (5) family income (Kronenberger et al., 2013); (6) nonverbal intelligence (Castellanos et al., 2016); (7) communication mode (Geers et al., 2003); (8) duration of CI use (Calmels et al., 2004); (9) the onset of hearing loss (Dowell et al., 2002); (10) aetiology of deafness such as meningitis or auditory neuropathy spectrum disorder (Ehrmann-Müller et al., 2020;Liu et al., 2015); and (11) residual hearing (Zwolan et al., 1997). ...
... Non-computerized visual DS tasks have also been used to assess verbal STM and verbal WM in long-term CI users. In visual DS tasks, the participants should say the digits on-screen out loud (AuBuchon et al., 2015a;Castellanos et al., 2018). Similar to the previous studies, for DSF task, the TH participants score significantly higher than long-term CI users (AuBuchon et al., 2015a). ...
... Thus, previous knowledge can be integrated with the present information (Dehn, 2008). Castellanos et al. (2018) reported that long-term CI users with better verbal and visuospatial WM skills have fewer attention problems, which is crucial for learning. Castellanos et al. (2018) also reported that psychosocial outcomes (social, behavioural, and emotional) in long-term CI users are associated mainly with WM skills and several areas of executive functioning and spoken language. ...
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Short-term memory (STM) and working memory (WM) capacity, which are at the centre of information processing, are significant predictors of learning in both children with typical hearing (TH) and hearing loss. We compared the performance of long-term cochlear implant (CI) users with their typical hearing (TH) peers on verbal short-term memory (STM), verbal working memory (WM), visuospatial STM, and visuospatial WM. Through a database search, we identified relevant articles published up to 14 February 2021. Twenty articles met the inclusion criteria for a systematic analysis. Meta-analysis was performed on both verbal STM and WM. Limitation in verbal STM was found to have a large effect size, and limitation in verbal WM was found to have a medium to large effect size in long-term CI users in a WM task. There was no significant difference between long-term CI users and their TH peers in two verbal WM (reading span and visual digit span) tasks. Results revealed that the long-term CI users have more difficulty in storing than processing information. The outcomes of this meta-analysis have clinical and educational implications for CI users. The visual representation of verbal items compensated for the limitation in verbal WM in long-term CI users. The opposite was observed for verbal STM tasks. A significant difference between TH and long-term CI users was observed for the visuospatial STM with a small to medium effect size in individual studies. However, our findings should be interpreted very cautiously in this preliminary systematic review and meta-analysis because of small samples. All interpretations have been made according to current findings. There is a need for more studies about verbal and visuospatial STM and WM in long-term CI users.
... Nevertheless, this protocol is intended to be generally applicable to researchers using a variety of head-mounted eye-tracking systems to study a variety of topics in infant and child development. Though optimal use of this protocol will involve study-specific tailoring, the adoption of these general practices have led to successful use of this protocol in a variety of contexts (see Figure 1), including the simultaneous head-mounted eye tracking of parents and toddlers 7,8,9,10 , and head-mounted eye tracking of clinical populations including children with cochlear implants 15 and children diagnosed with autism spectrum disorders 16,17 . ...
... Thus, "fixations" of visual attention cannot be easily and accurately determined from only the POG data. For further information on issues associated with identifying fixations in head-mounted eye tracking data, please consult other work 15,22 . Manually coding data frame-by-frame for ROI can require extra time compared to coding fixations. ...
Young children's visual environments are dynamic, changing moment-by-moment as children physically and visually explore spaces and objects and interact with people around them. Head-mounted eye tracking offers a unique opportunity to capture children's dynamic egocentric views and how they allocate visual attention within those views. This protocol provides guiding principles and practical recommendations for researchers using head-mounted eye trackers in both laboratory and more naturalistic settings. Head-mounted eye tracking complements other experimental methods by enhancing opportunities for data collection in more ecologically valid contexts through increased portability and freedom of head and body movements compared to screen-based eye tracking. This protocol can also be integrated with other technologies, such as motion tracking and heart-rate monitoring, to provide a high-density multimodal dataset for examining natural behavior, learning, and development than previously possible. This paper illustrates the types of data generated from head-mounted eye tracking in a study designed to investigate visual attention in one natural context for toddlers: free-flowing toy play with a parent. Successful use of this protocol will allow researchers to collect data that can be used to answer questions not only about visual attention, but also about a broad range of other perceptual, cognitive, and social skills and their development.
... Many studies have shown that hearing parents of children with hearing loss tend to be more directive in their interactions than hearing parents of NH children (Fagan, Bergeson, & Morris, 2014;Henggeler, Watson, & Cooper, 1984). For example, parents of children with hearing loss tend to use more directives and prohibitions in their speech than parents of age-matched NH children (Castellanos, Pisoni, Yu, Chen, & Houston, 2018;Chen, Castellanos, Yu, & Houston, 2019a;Fagan et al., 2014;Henggler et al., 1984). One possible outcome of these directive parental styles is that parents of children with hearing loss may be less likely to provide names of referents when their children are attending to a particular referent, because they may be less likely to follow the children's lead. ...
Full-text available
It is generally assumed that deaf and hard-of-hearing children’s difficulties in learning novel words stem entirely from impaired speech perception. Degraded speech perception makes words more confusable, and correctly recognizing words clearly plays an important role in word learning. However, recent findings suggest that early auditory experience may affect other factors involved in linking the sound patterns of words to their referents. This chapter reviews those findings and discusses possible factors that may be affected by early auditory experience and, in turn, also affect the ability to learn word-referent associations. These factors include forming representations for the sound patterns of words, encoding phonological information into memory, sensory integration, and quality of language input. Overall, we learn that in order to understand and to help mitigate the difficulties deaf and hard-of-hearing children face in learning spoken words after cochlear implantation, we must look well beyond speech perception.
... Our results showed significant group differences between children with and without hearing loss. One explanation is that parents in the HL group may be more directive and (therefore) less sensitive to children's attentional state (Castellanos, Pisoni, Yu, Chen, & Houston, 2018). Alternatively, it could also be that they are less attuned to providing information about the object of children's interest at the optimal time. ...
Children's attentional state during parent-child interactions is important for word learning. The current study examines the real-time attentional patterns of toddlers with and without hearing loss (N = 15, age range: 12–37 months)in parent-child interactions. High-density gaze data recorded from head-mounted eye-trackers were used to investigate the synchrony between parents’ naming of novel objects and children's sustained attention on the named objects in joint play. Results show that the sheer quantities of parents’ naming and children's sustained attention episodes were comparable in children with hearing loss and their peers with normal hearing. However, parents’ naming and children's sustained attention episodes were less synchronized in the hearing loss group compared to children with normal hearing. Possible implications are discussed.
p>The article analyzes the specifics of the organization of the perceptual activity of preschoolers with and without hearing impairment with different forms of instruction in the learning process. A comparative study of a sample of children aged 4-6 years was carried out: typically developing and with sensorineural hearing loss after cochlear implantation. During the experiment, the combinations of verbal and non-verbal instructions were varied. During the training task, eye movements were recorded by a Pupil Labs mobile tracker in the form of glasses. When changing the forms of instructions in 4 series of the experiment, it was found that a measure of reducing visual attention in the learning process in children with hearing impairment is changes in the periods of fixations when they are focused on the regions targeted for the learning task (such as a form for completing the task, a sample, an adult's face) . In children with hearing impairment, during the learning process, a transformation of perceptual processes was recorded depending on the form of the instruction: whether fixation on non-target stimuli decreases, fixation occurs faster or slower, whether the cognitive complexity of information decreases, whether fixation will be longer in target areas, whether there is constant attention and shared attention with an adult. It is shown how a different form of instruction allows you to restructure the perception of a child with hearing impairment, focusing attention on the elements relevant to the task. Differences in the change in the perceptual activity of typically developing preschoolers and preschoolers with hearing impairment were analyzed with different forms of instruction. It was found that the movement of the eyes of children with hearing impairment, unlike their peers, can be characterized by a significant reduction in orienting perceptual actions. The most effective for children with hearing impairment is the simultaneous use of multimodal means of explaining instructions or separately non-verbal forms of instructions (showing an action or a sample). For typically developing children, non-verbal forms of instruction without verbal accompaniment are not as effective.</p
Full-text available
This chapter extends the analyses presented previously. First, intercorrelations among variables are investigated across behavioral and developmental domains at 18 months for all four groups. Second, two groups are created-one including all dyads with a deaf child and another including all dyads with a hearing child. Predictions of 12- and 18-month measures are then considered for all of the deaf children and, separately, for all of the hearing children. The focus of this set of analyses will be on the predictive power of specific observable mother and child behaviors, many of which are amenable to intervention, instead of the pre-existing, immutable characteristic of matched or unmatched hearing status.
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This study investigated if a period of auditory sensory deprivation followed by degraded auditory input and related language delays affects visual concept formation skills in long-term prelingually deaf cochlear implant (CI) users. We also examined if concept formation skills are mediated or moderated by other neurocognitive domains (i.e., language, working memory, and executive control). Relative to normally hearing (NH) peers, CI users displayed significantly poorer performance in several specific areas of concept formation, especially when multiple comparisons and relational concepts were components of the task. Differences in concept formation between CI users and NH peers were fully explained by differences in language and inhibition-concentration skills. Language skills were also found to be more strongly related to concept formation in CI users than in NH peers. The present findings suggest that complex relational concepts may be adversely affected by a period of early prelingual deafness followed by access to underspecified and degraded sound patterns and spoken language transmitted by a CI. Investigating a unique clinical population such as early-implanted prelingually deaf children with CIs can provide new insights into foundational brain-behavior relations and developmental processes. © The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail:
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Parental involvement and communication are essential for language development in young children. However, hearing parents of deaf children face challenges in providing language input to their children. This study utilized the largest national sample of deaf children receiving cochlear implants, with the aim of identifying effective facilitative language techniques. Ninety-three deaf children (≤ 2 years) were assessed at 6 implant centers prior to and for 3 years following implantation. All parent–child interactions were videotaped, transcribed, and coded at each assessment. Analyses using bivariate latent difference score modeling indicated that higher versus lower level strategies predicted growth in expressive language and word types predicted growth in receptive language over time. These effective, higher level strategies could be used in early intervention programs.
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A large body of evidence supports the importance of focused attention for encoding and task performance. Yet young children with immature regulation of focused attention are often placed in elementary-school classrooms containing many displays that are not relevant to ongoing instruction. We investigated whether such displays can affect children's ability to maintain focused attention during instruction and to learn the lesson content. We placed kindergarten children in a laboratory classroom for six introductory science lessons, and we experimentally manipulated the visual environment in the classroom. Children were more distracted by the visual environment, spent more time off task, and demonstrated smaller learning gains when the walls were highly decorated than when the decorations were removed.
The history of deaf education reveals a constant competition between perspectives and wide differences of opinion about the nature of best practice. All too often, the discourse has centered on “obvious” solutions to the educational challenges faced by deaf and hard-of-hearing (DHH) learners and offers of a One True Path to better academic outcomes. These “solutions” frequently have lacked an evidence base or, at best, have been examined only for a particular subgroup of learners or those in a particular educational setting—despite the long-accepted recognition that DHH learners are extremely diverse. The current context of education for DHH learners and where it is headed is examined, emphasizing that it is time for the field to recognize that a one-size-fits-all approach to communication, school setting, or sociocultural environment simply cannot be appropriate for all or even most DHH learners.
The ability to sustain attention is a major achievement in human development and is generally believed to be the developmental product of increasing self-regulatory and endogenous (i.e., internal, top-down, voluntary) control over one's attention and cognitive systems [1-5]. Because sustained attention in late infancy is predictive of future development, and because early deficits in sustained attention are markers for later diagnoses of attentional disorders [6], sustained attention is often viewed as a constitutional and individual property of the infant [6-9]. However, humans are social animals; developmental pathways for seemingly non-social competencies evolved within the social group and therefore may be dependent on social experience [10-13]. Here, we show that social context matters for the duration of sustained attention episodes in one-year-old infants during toy play. Using head-mounted eye tracking to record moment-by-moment gaze data from both parents and infants, we found that when the social partner (parent) visually attended to the object to which infant attention was directed, infants, after the parent's look, extended their duration of visual attention to the object. Looks to the same object by two social partners is a well-studied phenomenon known as joint attention, which has been shown to be critical to early learning and to the development of social skills [14, 15]. The present findings implicate joint attention in the development of the child's own sustained attention and thus challenge the current understanding of the origins of individual differences in sustained attention, providing a new and potentially malleable developmental pathway to the self-regulation of attention.
This book provides both a review of the literature and a theoretical framework for understanding the development of visual attention from infancy through early childhood, including the development of selective and state-related aspects in infants and young children as well as the emergence of higher controls on attention. They explore individual differences in attention and possible origins of ADHD.