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Copyright © 2017 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
Relations Between Self-reported Executive Functioning and
Speech Perception Skills in Adult Cochlear Implant Users
Aaron C. Moberly, Tirth R. Patel, and Irina Castellanos
Department of Otolaryngology – Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
Hypothesis: As a result of their hearing loss, adults with
cochlear implants (CIs) would self-report poorer executive
functioning (EF) skills than normal-hearing (NH) peers, and
these EF skills would be associated with performance on
speech recognition tasks.
Background: EF refers to a group of high order neurocogni-
tive skills responsible for behavioral and emotional regula-
tion during goal-directed activity, and EF has been found to
be poorer in children with CIs than their NH age-matched
peers. Moreover, there is increasing evidence that neurocog-
nitive skills, including some EF skills, contribute to the
ability to recognize speech through a CI.
Methods: Thirty postlingually deafened adults with CIs and
42 age-matched NH adults were enrolled. Participants and
their spouses or significant others (informants) completed
well-validated self-reports or informant-reports of EF, the
Behavior Rating Inventory of Executive Function – Adult
(BRIEF-A). CI users’ speech recognition skills were assessed
in quiet using several measures of sentence recognition. NH
peers were tested for recognition of noise-vocoded versions
of the same speech stimuli.
Results: CI users self-reported difficulty on EF tasks of
shifting and task monitoring. In CI users, measures of speech
recognition correlated with several self-reported EF skills.
Conclusion: The present findings provide further evidence
that neurocognitive factors, including specific EF skills, may
decline in association with hearing loss, and that some of
these EF skills contribute to speech processing under
degraded listening conditions. Key Words: Cochlear
implants—Cognition—Executive functioning—Hearing loss.
Otol Neurotol 39:250–257, 2018.
Executive functioning (EF) refers to a group of high
order neurocognitive skills responsible for behavioral
and emotional regulation during goal-directed activity
(1,2). These skills are necessary to identify, process, plan,
and complete everyday tasks. Core EF includes abilities
such as sustained attention to a task, working memory
(WM), inhibition of competing actions or thoughts, and
the ability to shift attention appropriately (3). Other
higher level neurocognitive skills—including processing
of information, planning a course of action, organization
of materials, and problem solving—are dependent on
these core EF skills (1,3).
During early childhood, EF pathways in the prefrontal
cortex begin to develop (4), experience a period of rapid
growth during the preschool years, mature in adoles-
cence, and decline in older age (5). Because auditory
deprivation has been associated with the disorganization
of developing cortical pathways in children (6), it has
been proposed that hearing ability is crucial to the
development of EF in childhood (7). Studies measuring
EF using performance and questionnaire-based assess-
ments in children with hearing loss provide support for
this premise: prelingually deafened children with severe-
to-profound hearing loss who use cochlear implants
(CIs), devices that permit access to sound but provide
highly degraded sensory input, have been shown to have
significant deficits in EF skills compared with their
normal hearing (NH) age-matched peers (2,8). Even after
long-term device use, most children with CIs do not
demonstrate EF skills comparable to NH children (9).
At the other end of the age spectrum, hearing loss in
older adults has been associated with cognitive declines
(10). In general, based on studies of adults with mild-to-
moderate degrees of hearing loss, there seems to be a
small but significant association between degree of hear-
ing loss and severity of cognitive declines, as well as a
greater incidence of clinically significant cognitive
impairment in adults with impaired hearing (11 – 13).
However, these studies typically examine neurocognitive
Address correspondence and reprint requests to Aaron C. Moberly,
M.D., 915 Olentangy River Road, Columbus, OH 43212; E-mail:
Aaron.Moberly@osumc.edu
This work was supported by the National Institutes of Health,
National Institute on Deafness and Other Communication Disorders
(NIDCD) Career Development Award 5K23DC015539-02 and the
American Otological Society Clinician-Scientist Award to ACM.
ResearchMatch, used to recruit some NH participants, is supported
by National Center for Advancing Translational Sciences Grant
UL1TR001070.
Data presented in this manuscript were presented in a poster presen-
tation at the American Otological Society meeting at COSM,
April 2017, San Diego, CA.
The authors disclose no conflicts of interest.
DOI: 10.1097/MAO.0000000000001679
250
Otology & Neurotology
39:250– 257 ß2017, Otology & Neurotology, Inc.
Copyright © 2017 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
functions using relatively broad screening measures of
general cognition (e.g., the Mini Mental State Examina-
tion or the Modified Mini Mental State Examination) or
assess only a small number of neurocognitive functions
that could be considered tests of EF (e.g., the Digit
Symbol Substitution Test of psychomotor speed) (12).
Moreover, few studies have specifically examined EF in
adults with severe-to-profound postlingual hearing loss
who use CIs. Unlike patients with mild-to-moderate
hearing loss, postlingually deafened adult CI users rep-
resent a population with more severe hearing loss, and
who typically experience a relatively long duration of
auditory deprivation. Examining this clinical population
of postlingually deafened adults with CIs will allow us to
examine the extent to which prolonged auditory depri-
vation is associated with significant declines in EF, and
the degree to which demographic and audiologic patient
measures are associated with these declines.
To our knowledge, there have been only a few previous
attempts to compare the EF of postlingual adult CI users
and adults with NH, and these studies have primarily
obtained performance measures of WM (14,15).
Moberly, Harris, Boyce, and Nittrouer (16) recently
compared basic WM skills for auditory stimuli in adult
CI users and age-matched NH peers using tasks of digit
span and serial recall of monosyllabic words. Accuracy
scores and response times were similar between groups
for digit span, but accuracy scores on serial recall of
words were slightly poorer for CI users than NH controls.
In another recent study, neurocognitive functions were
assessed using nonauditory tasks in adult CI users and
NH peers, using visually presented tasks assessing global
intellectual abilities, WM, inhibition-concentration, and
controlled fluency (17). Neurocognitive functions were
similar between groups for all tasks except WM, on
which CI users scored significantly more poorly. These
findings provide some support for the premise that adult
CI users may have poorer EF than their NH counterparts,
particularly on tasks requiring WM.
An issue that limits the clinical relevance of these
previous studies of EF in adult CI users is the artificial
nature of the laboratory behavioral tasks used to investi-
gate and quantify these skills (9,12,18). These methods
typically consist of tasks that participants would not
perform in daily life. As a result, laboratory testing is
unlikely to reveal participants’ abilities pertaining to
daily goal-oriented tasks. As an alternative, self-report
questionnaires may provide additional methods for quan-
tifying EF skills. Questionnaire data are complementary
to laboratory performance-based data and provide infor-
mation about real-world behavior within the participants’
daily environment. Questionnaires are diagnostically
valuable, clinically useful for tracking functioning and
progress across time, simple to administer, and easy to
interpret (19). Additionally, informant-report question-
naires of EF, completed by a family member or close
friend, can serve as an additional source of information
regarding patients’ EF skills in daily life, and can be
completed even in a setting in which self-report
questionnaires cannot be completed (e.g., cognitive dys-
function, illiteracy). To our knowledge, neither self-
report nor informant-report questionnaires of EF have
been studied in adult postlingually deafened CI users.
Finally, there is growing evidence that EF skills under-
lie speech recognition abilities in patients with hearing
loss, including postlingual adults with CIs. For example,
in the Moberly et al. study, response times during a
laboratory measure of inhibition-concentration corre-
lated significantly with scores on a task of sentence
recognition in noise for adult CI users (17). Other studies
have demonstrated associations of scores on WM tasks
with speech recognition in adults with milder degrees of
hearing loss (20,21). An additional aim of the current
study was to investigate the relations between scores on
self-report measures of EF and several assessments of
auditory-only and audiovisual speech recognition. Iden-
tifying significant associations would suggest that a self-
report measure of EF could potentially serve as a clini-
cally useful preoperative outcome predictor, or could
help to explain outcome variability in adult CI users,
including in those who experience unexpected poor
speech recognition outcomes.
In summary, this study investigated four primary
questions concerning EF in adult CI users. First, do
postlingually deafened CI users self-report deficits in
everyday EF skills, compared with their age-matched NH
peers? Second, based on previous reports suggesting that
cognitive decline seems to occur commensurate with
degree of hearing loss and/or age (12,22), to what extent
are self-reported everyday EF skills associated with
traditional audiological and demographic measures in
CI users? Third, to examine CI users’ self-awareness
of potential deficits in everyday EF, we examined
whether CI users’ self-reported EF skills were corrobo-
rated by informant-reports of patient EF. Lastly, we
examined whether self-reported EF skills are associated
with the recognition of words in sentences presented
under auditory-only and synchronous audiovisual stimu-
lation. To address these questions, we administered self-
and informant-report versions of the Behavior Rating
Inventory of Executive Function-Adult Version (BRIEF-
A), a well-validated questionnaire assessing EF skills in
everyday life, along with speech recognition tests that
varied in complexity, cognitive demand, and need for
audiovisual integration (23). Developing a better under-
standing of EF in adult CI users should provide insight
into the role of auditory input in the maintenance of EF
skills in adults or, conversely, the detrimental effects of a
lack of auditory input for clinical populations with
hearing loss, as well as the relation of EF to speech
recognition outcomes in this clinical population of
CI users.
METHODS
Participants
All CI participants experienced postlingual hearing loss
during childhood or adulthood and were implanted after age
SELF-REPORTED EXECUTIVE FUNCTIONING 251
Otology & Neurotology, Vol. 39, No. 2, 2018
Copyright © 2017 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
18 years, and all had greater than 18 months of CI experience.
CI users demonstrated CI-aided thresholds better than 35 dB HL
at 0.25, 0.5, 1, and 2kHz, as measured by clinical audiologists
within 12 months before enrollment in the current study. Thirty
postlingually deafened adults with CIs were enrolled, along
with 42 adults with age-normal hearing. These participants were
a subset of participants who presented for a larger study
examining speech recognition abilities. Demographic and audi-
ological data are presented in Table 1. All CI users had Cochlear
(Sydney, Australia) devices, and used an Advanced Combined
Encoder speech processing strategy. Thirteen (43.3%) CI par-
ticipants used a right CI, eight (26.7%) used a left device, and
nine (30%) used bilateral devices. Twelve (40%) participants
wore a contralateral hearing aid. During testing, participants
used their devices in everyday mode, including use of any
contralateral aids, and kept the same settings throughout testing.
Unaided audiometric assessment was performed before speech
recognition testing to assess residual hearing in each ear.
CI users were matched as a group on chronological age with
NH controls. NH control participants were recruited from
patients with noncommunication complaints in the Department
of Otolaryngology, along with the use of a national research
recruitment database, ResearchMatch. Participants in the NH
control sample were evaluated for age-NH immediately before
speech recognition testing, with NH defined as four-tone (0.5, 1,
2, and 4 kHz) pure-tone average (PTA) of better than 25 dB HL
in the better ear. This criterion was relaxed to a PTA of 30 dB
HL for individuals over 60 years old, but only 4 had a PTA
worse than 25 dB HL.
American English was the first language for all CI and NH
participants. All had graduated from high school, except for one CI
user who earned his General Education Diploma (GED). Our
measure of socioeconomic status (SES) was quantified using a
metric defined by Nittrouer and Burton (24), indexing occupational
and educational levels, with two scales between 1 and 8, with
scores of 8 as the highest level achievable. The two scores were
multiplied, resulting in SES scores between 1 and 64.
All participants underwent screenings for cognitive, reading,
and vision abilities. The Mini-Mental State Examination (MMSE),
a well-validated screening tool for cognition, was used to rule out
evidence of cognitive impairment (25). Raw scores of less than 26
are concerning for cognitive impairment; however, all participants
had scores 26. A computerized Raven’s Progressive Matrices
was used to assess global nonverbal intelligence (26). The Raven’s
presents geometric designs in a matrix where each design contains
a missing piece, and participants must complete the pattern by
selecting a response box. An abbreviated version of the Raven’s
test was conducted over 10 minutes. Raw scores were used as the
measure of nonverbal intelligence. The Word Reading subtest of
the Wide Range Achievement Test, 4th edition (WRAT), was used
to assess basic word-reading ability (27). All participants demon-
strated a standard score on the WRAT 80. A final screening test
of near-vision was performed; all participants had corrected near-
vision of better than or equal to 20/40.
Procedure
All the procedures were approved by the Institutional
Review Board of The Ohio State University, and written
informed consent was obtained. For CI users, sound detection
with device use was confirmed before testing. All performance-
based tasks were performed in a soundproof booth or a sound-
treated testing room. For the MMSE and WRAT screening
tasks, as well as the sentence recognition tasks, participant
responses were video-and audio-recorded for later scoring.
Questionnaire-based Measures: Executive
Functioning
Participants completed a self-report version of the BRIEF-A.
A subset of the CI users (27, 93%) and NH controls (35, 83%)
TABLE 1. Demographic and hearing history of cochlear implant (CI) users and normal-hearing (NH) controls
CI User N¼30 NH N¼42
Mean (SD) Range Mean (SD) Range
Age at testing 66.47 (8.85) 50.00– 81.00 67.67 (6.62) 50.00– 81.00
PTA 100.17 (15.73) 70.00– 120.00 16.43 (7.22) 6.25 – 30.00
Nonverbal IQ 10.90 (4.25) 5.00– 20.00 12.86 (5.73) 5.00– 26.00
MMSE 28.77 (1.25) 26.00– 30.00 29.26 (0.91) 26.00– 30.00
WRAT 98.30 (12.41) 78.00– 122.00 102.17 (9.79) 82.00– 126.00
SES 24.69 (13.41) 6.00– 56.00 36.15 (14.55) 9.00– 64.00
Count (% of sample)
Hearing device
CI and HA 12 (40.0)
Bilateral CIs 9 (30.0)
Unilateral CI alone 9 (30.0)
Etiology of hearing loss
Unknown 13 (44.8)
Hereditary 14 (44.8)
Ototoxicity 2 (6.9)
Menie`re’s disease 1 (3.4)
Sex
Female 13 (43.3) 28 (66.67)
Male 17 (56.7) 14 (33.33)
Note. Unaided pure-tone average (PTA) in the better ear for the frequencies 250, 500, 1000, and 2000 Hz in dB HL. Nonverbal IQ scores are
expressed as raw scores from the Raven’s Progressive Matrices. The Mini-Mental State Examination (MMSE) assesses cognitive impairments
and dementia. The Wide Range Achievement Test (WRAT) assesses word reading ability.
252 A. C. MOBERLY ET AL.
Otology & Neurotology, Vol. 39, No. 2, 2018
Copyright © 2017 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
also had an ‘‘informant’’ (most commonly a spouse or signifi-
cant other) evaluate their EF skills by completing the informant-
report version of the BRIEF-A scale. The BRIEF-A scale is
applicable to adults 18 years and older and is completed in
approximately 10 minutes.
The BRIEF-A is a 75-item questionnaire of behavioral
problems during the past month and includes nine domains
of EF: Inhibit, Shift, Emotional Control, Working Memory,
Plan/Organize, Initiate, Task Monitor, Organization of Materi-
als, and Self-Monitor. Each EF item is rated on a 3-point
severity scale (never, sometimes, often). Subscales are aggre-
gated to create two broad indices, Behavioral Regulation and
Metacognition, along with a Global Executive Composite
score. The Behavioral Regulation Index is a composite of
the Inhibit, Shift, Emotional Control, and Self-Monitor sub-
scales, whereas the Metacognition Index is a composite of the
remaining five subscales, Working Memory, Plan/Organize,
Initiate, Task Monitor, and Organization of Materials. The
Global Executive Composite score is the composite of all nine
subscales. Raw scores on the BRIEF-A were converted to T
scores and compared against our sample of NH age-matched
control participants, as well as with a nationally representative
sample of 1,136 adults aged 18 to 90. Higher scores on the
BRIEF-A indicate greater problems with everyday EF skills.
Performance-based Measures: Speech Recognition
Three prerecorded sentence lists were used to examine the
recognition of words in sentences: 1) The City University of
New York (CUNY) consists of 3 sets of 12 topic-related
sentences presented in an audiovisual (AV), auditory-only
(A), or visual-only (V) format, with order of presentation
(AV, A, V) counterbalanced across participants (28). 2) IEEE
consists of 28 relatively complex sentences with a moderate
degree of sentential context (29). 3) The Perceptually Robust
English Sentence Test Open-set (PRESTO) consists of 30 high-
variability sentences and incorporates variation in talkers,
dialects, and number of words in a sentence (30). CI users
were tested in quiet, while NH listeners were tested using 8-
channel noise-vocoding to provide spectral degradation similar
to the speech processing performed by a CI. Vocoding was
conducted using vocoder software in MATLAB, using a
Greenwood function with speech-modulated noise. Percent
correct words for each sentence type served as our measure
of interest.
RESULTS
CI and NH samples did not differ on age (t(70) ¼0.66,
p¼.51), Raven’s nonverbal IQ scores (t(70) ¼1.58,
p¼.12), WRAT reading and MMSE cognitive screening
tests (t(70) ¼1.48, p¼.14; t(70) ¼1.94, p¼.06,
respectively), or sex ( p¼.06 by Fisher’s exact test;
Table 1). CI participants, however, had significantly lower
SES than their NH peers (t(68) ¼3.35, p<.01).
Self- and informant-reported EF scores for CI users
and NH controls are shown in Table 2. BRIEF-A scores
were not significantly different when comparing bilateral
CI users, bimodal CI users (CI plus contralateral hearing
aid), and unilateral CI-only users. Compared against the
BRIEF-A national norms, CI users self-reported signifi-
cantly greater problems in shifting and task monitoring (t
(29) ¼2.39, p¼.02, t(29) ¼2.63, p¼.01, respectively),
while NH peers self-reported significantly greater prob-
lems with working memory (t(41) ¼2.78, p<.01).
However, CI users and NH peers self-reported compara-
ble EF on all the subscales and indices of the BRIEF-A.
When we compared self versus informant BRIEF-A
scores, results revealed that CI users self-reported sig-
nificantly greater problems in 5 subscales (shifting,
emotional control, working memory, and task monitor-
ing) and 2 indices (Behavioral Recognition and Global
Executive Composite), as compared with informant
reports. In the NH sample, results revealed convergence
between the self and informant reported EF skills.
EF Associations With Demographic and Hearing
History Variables
Correlations of BRIEF-A scores with traditional
demographic and hearing history variables for CI users
TABLE 2. Self and informant-reported executive functioning in cochlear implant (CI) users and normal-hearing (NH) controls
Self-report Informant-report
CI User N¼30 NH N¼42 CI User N¼27 NH N¼35
BRIEF-A Mean SD Mean SD Mean SD Mean SD
Inhibit 49.47 6.54 50.81 8.25 46.81 6.83 48.23 8.24
Shift 53.939.00 50.83 10.74 45.96 6.20 48.94 10.01
Emotional Control 52.40 9.43 48.86 9.63 48.00 8.66 46.34 10.18
Self Monitor 49.33 8.28 48.05 12.42 49.42 8.54 46.60 9.72
Initiate 50.97 8.80 52.79 12.35 51.11 8.86 50.71 12.07
Working Memory 51.33 8.92 54.5510.61 47.85 5.99 51.49 12.07
Plan/Organize 50.87 10.36 51.36 10.86 48.89 8.80 48.49 10.62
Task Monitor 54.509.39 52.86 11.87 49.48 7.80 48.97 11.74
Organization of Material 50.83 7.91 51.19 12.45 51.15 9.47 50.97 10.74
Behavioral Recognition Index 51.70 7.77 49.48 10.82 47.77 7.20 47.06 10.40
Metacognition 51.77 8.14 52.74 11.73 49.67 7.40 49.74 10.89
Global Executive Composite 51.80 7.20 52.00 12.74 – – – –
Note. BRIEF-A subscale scores are expressed as Tscores (M¼50, SD ¼10). Subscale scores in bold represent scores that are significantly
(p<.05 based on one-tailed tests) greater than the normative mean.
SELF-REPORTED EXECUTIVE FUNCTIONING 253
Otology & Neurotology, Vol. 39, No. 2, 2018
Copyright © 2017 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
are shown in Table 3. In terms of demographic variables,
younger chronological age was associated with better
self-reported BRIEF-A emotional control, self monitor-
ing, organization of materials, and Behavioral Recogni-
tion Index. Higher nonverbal IQ was associated with
better self-reported BRIEF-A emotional control, self
monitoring, and organization of materials. Higher SES
was associated with better emotional control, self moni-
toring, Behavioral Recognition Index, and Global Exec-
utive Composite scores. In terms of hearing history
variables, better PTAs were associated with better orga-
nization of materials in CI users. Shorter duration of
deafness was associated with better self-reported emo-
tional control and Behavioral Recognition Index. Addi-
tionally, longer duration of CI use was associated with
better self-reported shifting and initiation.
EF Associations With Speech Recognition Skills
Correlations of BRIEF-A scores with speech recogni-
tion are shown in Table 4. To summarize, in CI users,
better performance in the CUNY AV and CUNY A
sentence recognition tasks was associated with better
self-reported BRIEF-A scores of emotional control, self
monitoring, planning/organizing, Behavioral Recogni-
tion Index, and Global Executive Composite scores.
Performance in CUNY V was only associated with self
monitoring in the CI users. In contrast, performance in
the CUNY A and CUNY AV sentence recognition task
was not associated with any of the BRIEF-A subscales or
indices in the NH sample, but better performance in
CUNY V was associated with better self-reported shift-
ing, initiation, planning/organizing, organization of
materials, Metacognition Index, and Global Executive
Composite scores on the BRIEF-A.
Turning to the IEEE and PRESTO sentences, better
performance on the IEEE sentence recognition task was
associated with better self-reported emotional control,
self monitoring, and Behavioral Recognition Index
scores in CI users. In NH controls, better performance
on IEEE sentences was associated with better task
TABLE 3. Correlations between self-reported executive functioning and demographic/hearing history variables in cochlear
implant (CI) users
BRIEF-A Age Nonverbal IQ SES PTA Duration of Deafness Duration of CI Use
Inhibit .05 .11 .26 .16 .23 .29
Shift .01 .05 .31 .07 .04 S.33
Emotional Control .31S.32S.51 .06 .40.11
Self Monitor .60 S.32S.34.12 .17 .01
Initiate .18 .12 .07 .15 .02 S.32
Working Memory .15 .12 .22 .13 .18 .08
Plan/Organize .09 .28 .24 .08 .21 .23
Task Monitor .10 .01 .27 .23 .14 .05
Organization of Material .36.37.21 .48 .20 .02
Behavioral Recognition Index .32.22 S.52 .07 .32.23
Metacognition .01 .05 .23 .08 .10 S.18
Global Executive Composite .14 .15 S.43.08 .23 .23
Note.N¼30 CI users. p<.01; p<.05 based on one-tailed tests.
Bold indicates significant values at p<.05.
TABLE 4. Correlations between self-reported executive functioning and speech recognition skills in cochlear implant (CI) users
and normal-hearing (NH) controls
BRIEF-A
CUNY AV CUNY A CUNY V IEEE PRESTO
CI NH CI NH CI NH CI NH CI NH
Inhibit .24 .05 .18 .19 .10 .15 .24 .15 .03 .26
Shift .22 .04 .01 .26 .16 S.28.02 .25 .06 .17
Emotional Control S.53 .15 S.50 .13 .13 .17 S.43 .11 .29 .08
Self Monitor S.35.26 S.33.07 S.32.26 S.33.08 .16 .01
Initiate .23 .05 .14 .22 .26 S.38 .05 .15 .07 .20
Working Memory .15 .07 .04 .17 .14 .14 .01 .16 .11 .25
Plan/Organize S.47 .14 S.37.21 .29 S.33.24 .19 .27 .14
Task Monitor .06 .11 .09 .16 .15 .22 .04 S.28.09 .11
Organization of Material .14 .24 .07 .25 .19 S.33.14 .18 .16 .10
Behavioral Recognition Index S.48 .16 S.38.18 .16 .25 S.37.17 .15 .14
Metacognition .30 .15 .17 .24 .18 S.34.05 .21 .01 .18
Global Executive Composite S.46 .14 S.31.25 .19 S.32.23 .21 .09 .16
Note.N¼30 CI users, N¼42 NH peers. p<.01; p<.05 based on one-tailed tests.
Bold indicates significant values at p<.05.
254 A. C. MOBERLY ET AL.
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monitoring. However, performance on PRESTO senten-
ces was not associated with self-reported EF in CI users or
NH controls. Similar analyses were performed among all
speech recognition scores and informant-report BRIEF-A
scores, but no significant correlations were found.
DISCUSSION
This study examined the EF skills of postlingual adult
CI users, along with their NH age-matched peers. Four
questions were asked: First, do CI users self-report
deficits in everyday EF skills, compared with their NH
peers? Second, to what extent were self-reported EF
skills related to traditional audiological and demographic
measures in CI users? Third, how do CI users’ self-
reported EF skills compare with informant reports of
patient EF? And finally, how do self-report EF scores
relate to speech recognition measures?
Regarding the first question, CI users and their NH peers
were found to self-report comparable everyday EF skills.
However, when comparedagainst the normative sample of
adults, CI users self-reported significantly higher scores
(greater problems) on the BRIEF-A shifting and task-
monitoring subscales. This is consistent with findings of
worse EF in pediatric CI users, although EF deficits in that
population are more global across EF domains (7). It is
unclear specifically why the shifting and task monitoring
subscales were the only ones to reveal deficits by self-
report in adult CI users, and additional research will be
needed to explore these findings in more detail. However,
the general finding of poorer EF on some subscales in CI
users using self-report questionnaires suggests that these
deficits in EF are relevant to the everyday goal-directed
behaviors in this patient population. Moreover, this finding
suggests that highly refined auditory input is not only
important in the development of EF skills during child-
hood, but also may be important in the maintenance of
some particular EF skills—namely, shifting and task
monitoring—during adulthood. In contrast, NH peers in
this study self-reported significantly higher scores (greater
problems) on the BRIEF-A working memory subscale
when compared with national norms. It is unclear why
this finding occurred, but it suggests potential sampling
differences between our NH control sample and the
national normative sample.
The second question addressed in this study pertained
to the relationship between self-report scores of EF and
traditional audiological and demographic patient factors.
In general, younger age, higher nonverbal IQ, higher
SES, and better PTAs were associated with better self-
reported EF skills in CI users, at least in some domains.
We found data to support our hypothesis that longer
durations of auditory deprivation and shorter duration of
CI use were associated with poorer self-reported EF skills
in CI users, but again only across a few domains. A
limitation that should be considered is that our assess-
ment of duration of hearing loss was acquired from
patient self-report and was thus relatively insensitive.
Moreover, we could not determine the degree of hearing
impairment experienced by patients over their period of
auditory deprivation, except that they all experienced
bilateral severe-to-profound hearing loss by the time
of implantation.
The third question asked in this study was whether
self-report measures of everyday EF would be similar to
informant-report measures of functioning. In general,
self-report and informant-report scores were highly cor-
related for NH controls, but CI users self-reported poorer
EF compared with the reports from their informants.
Disparate findings between groups for informant- vs
self-reports of EF have previously been found in children
with hearing loss, and it has been suggested that this
indicates that individuals with hearing loss may be
burdened both with poorer language skills (or EF) and
poorer awareness of those deficits. In this sample of
adults with CIs, the opposite may be true: our adult CI
users rated themselves more poorly on EF skills than
informants. Regardless of the cause, this finding should
be taken into consideration if informant-report BRIEF-A
assessments were to be used clinically in this population.
The final question asked pertained to associations
between self-reported EF skills and speech recognition
skills. In general, several EF skills related significantly to
scores of speech recognition for CI users in the auditory-
only (CUNY and IEEE) and audiovisual (CUNY) con-
dition. It is particularly noteworthy that self-report mea-
sures of everyday EF related to audiovisual sentence
recognition, because this is the most typical communi-
cation scenario in which CI users find themselves during
face-to-face interactions (31). Moreover, the strongest
correlations between EF and speech recognition also
tended to be for stimuli presented under audiovisual
speech stimulation, which may suggest that audiovisual
speech integration is more cognitively demanding and/or
requires a higher degree of cognitive processing.
Findings from this study support the overall premise that
prolonged auditory deprivation is associated with cogni-
tive declines, at least for some EF skills, in agreement with
studies of adults with lesser degrees of hearing loss (32).
Several theories have been proposed to explain this rela-
tionship: 1) The ‘‘information-degradation’’ theory sug-
gests that declines in neurocognitive abilities manifest as a
consequence of the shifting of cognitive resources to
compensate for impaired auditory input (33,34). 2) The
‘‘sensory-deprivation’’ theory suggests that poor auditory
input directly leads to permanent cognitive impairments
(12,35). 3) The ‘‘common-cause’’ theory suggests that a
common mechanism underlies both auditory deprivation
and cognitive declines (36,37). 4) The ‘‘social isolation’’
theory, not mutually exclusive with the other three theo-
ries, suggests that hearing loss leads to social withdrawal
and subsequent cognitive declines (38,39). Although this
study was not designed directly to test these hypotheses,
findings provide cautious evidence against the ‘‘common-
cause’’ theory, because global deficits were not identified
across all domains of EF in CI users; instead, our findings
indicate that CI users self-report deficits in only two of the
domains examined.
SELF-REPORTED EXECUTIVE FUNCTIONING 255
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Copyright © 2017 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
There are a number of limitations to the present study.
First, a relatively small sample size was included, which
may have prevented identification of small differences in
everyday EF skills between CI and NH groups. Second,
the adults with hearing loss in this study were experi-
enced CI users, meaning they had received intervention
for their hearing loss. Although these patients had some
degree of restored auditory input through their devices,
raising the concern that the experience of CI use may
have affected EF abilities, these patients still experienced
a relative deficit in auditory input as a result of the
degraded nature of the CI signal. Nonetheless, a future
prospective study of self-report EF in adult CI candidates
with bilateral severe-to-profound hearing loss, along with
postoperative measures of EF after implantation and a
period of CI use, would allow the examination of the
effects of hearing loss, and the subsequent effects of CI
use, on EF abilities.
CONCLUSIONS
Adult postlingual CI users demonstrated deficits in
attention shifting and task monitoring, relative to NH
peers, and self-report EF scores correlated with some
measures of speech recognition. Findings provide addi-
tional support for the premise that hearing loss is associ-
ated with some specific cognitive declines, particularly
some everyday goal-directed EF skills. Additional stud-
ies will be required to directly assess the effects of
cochlear implantation on EF skills in adults with post-
lingual hearing loss.
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