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Versión en Español (muy pronto)

 

Factors Influencing Performance Outcomes

Developed by Debra Berlin Nussbaum, Coordinator, Cochlear Implant Education Center, Laurent Clerc National Deaf Education Center

Download the PDF version:

Continuum of Outcomes

There are varying levels of spoken language competence a child may achieve with a cochlear implant. While children with a cochlear implant can detect individual speech sounds, this does not automatically guarantee that they will develop the necessary skills to comprehend spoken language for learning. The process of "making sense" of the sound available through a cochlear implant and then developing the ability to use this auditory information to learn and communicate is individual to each child. Learning to listen and speak is sequential, one skill building upon another. Moving through the sequence happens more readily for some children than for others. In addition, some children move higher in the hierarchy of skill development than others.

These hierarchies are examples of the levels of competency a child may obtain with his or her cochlear implant. Progress in moving through these hierarchies requires training by therapists, family, and teachers who understand how to facilitate these skills. (See the module on Training the Ear to Listen.)

 

skill development chart

Factors Impacting Performance

Performance outcomes in listening, speaking, and spoken language are related to many complex and interactive factors. Each of these associated factors below should be taken into consideration in developing realistic expectations for spoken language growth and for making language, communication, and educational planning decisions.

Factors Related to the Child

Age of Implantation
Research and observation suggest that spoken language performance outcomes are best for those who are implanted very young when language is typically developing. This is the time when the brain most readily masters language. For children implanted at the youngest ages (prior to 18 months), spoken language appears to emerge most naturally. For later-implanted children (who did not have access to sound during the early years of their lives), observation and research suggest that although there is greater benefit from a cochlear implant compared with traditional hearing aids, existing auditory delays at the time of implantation present continued educational and rehabilitation challenges that oftentimes cannot be overcome. This is not to say that a cochlear implant may not be an appropriate choice for a later-implanted child, it is just to say that expectations should be guarded and realistic related to spoken language outcomes.

For more information on the age of implantation:

Dettman, S., Pinder, D., Briggs, R., Dowell, R., & Leigh, J. (2007). Communication development in children who receive the cochlear implant younger than 12 months: Risks versus benefit. Ear and Hearing, 28(2), 11S-18S.

Geers, A. E., Nicholas, J. G., & Sedey, A. L. (2003). Language skills of children with early cochlear implantation. Ear and Hearing, 24(1), 46S-58S.

Geers, A. E., Strube, M. J., Tobey, E. A., Pisoni, D. B.,& Moog, J. S. (2010). Epilogue: Factors contributing to long-term outcomes of cochlear implantation in early childhood. Ear and Hearing, 32(1), 84S-92S.

Holt, R., & Svirsky, M. (2008). An exploratory look at pediatric cochlear implantation: Is earliest always best? Ear and Hearing, 29, 492-511.

McConkey Robbins, A., Burton Koch, D., Osberger, M. J., Zimmerman-Phillips, S., & Kishon-Rabin, L. (2004). Effect of age at cochlear implantation on auditory skill development in infants and toddlers. Archives of Otolaryngology—Head & Neck Surgery, 130(5), 570-574.

Nicholas, J. G., & Geers, A. E. (2006, June). Effects of early auditory experience on the spoken language of deaf children at 3 years of age. Ear and Hearing, 27(3), 286-298.

Nicholas, J. G., & Geers, A. E. (2007). Will they catch up? The role of age at cochlear implantation in the spoken language development of children with severe to profound hearing loss. Journal of Speech, Language, and Hearing Research, 50(4), 1048-1062. doi:10.1044/1092-4388(2007/073)

Sharma, A., Dorman, M., & Kral, A. (2005). The influence of a sensitive period on central auditory development in children with unilateral and bilateral cochlear implants. Hearing Research, 203, 134-143.

Sommers, R. K., & Lim, S. (2006, July). How well do young children using cochlear implants succeed in the development of language, speech, and academic skills? What are current research findings telling us? Retrieved March 9, 2011, from http://www.auditoryoptions.org/research.htm

Spencer, L. J., Barker, B. A., & Tomblin, J. B. (2003). Exploring the language and literacy outcomes of pediatric cochlear implant users. Ear and Hearing, 24, 236-247. Retrieved March 9, 2011, from http://www.uiowa.edu/~clrc/pdfs/literacy.pdf

Svirsky, M. A., Teoh, S. W., & Neuburger, H. (2004). Development of language and speech perception in congenitally, profoundly deaf children as a function of age at cochlear implantation. Audiology Neurotology, 9(4), 224-233.

Waltzman, S., & Roland, T. (2005, October). Cochlear implantation in children younger than 12 months. Pediatrics, 116(4), e487-e493. Retrieved March 9, 2011, from http://pediatrics.aappublications.org/cgi/content/full/116/4/e487

Pre-implant Duration of Deafness
The shorter the time from identification of being deaf to the time of cochlear implantation, the easier it tends to be for a child to develop spoken language. Research suggests that the less time the auditory channels remain dormant and unused, the greater the chance for these pathways to demonstrate the plasticity to accept the new incoming information available through the cochlear implant. It is therefore necessary to understand the importance of stimulating auditory neural pathways via hearing aids as early and as consistently as possible to prepare for implantation.

For more information:

Sharma, A., Dorman, J., & Spahr, A. (2002). A sensitive period for the development of the central auditory system in children with cochlear implants: Implications for age of implantation. Ear and Hearing, 23, 532-539.

Sharma, A., Dorman, M., & Kral, A. (2005). The influence of a sensitive period on central auditory development in children with unilateral and bilateral cochlear implants. Hearing Research, 203, 134-143.

Sharma, A., Tobey, E., Dorman, M., Martin, K., Gilley, P., & Kunkel, F. (2004). Central auditory maturation and babbling development in infants with cochlear implants. Archives of Otolaryngology—Head & Neck Surgery, 130(5), 511-516.

Language Competence
When parents and children communicate effectively with each other from the time the child is identified with a hearing loss, a foundation for language acquisition (both spoken and signed languages) is established, and language delays may be prevented or minimized. This also applies to children who obtain cochlear implants. It appears that children who have a strong language foundation (whether signed or spoken) before getting a cochlear implant have an easier time developing spoken language using their implant. It has been demonstrated that children who have had early exposure to language via sign (either as a support to spoken English or through American Sign Language [ASL]) can transition well to spoken language following implantation once the technology and spoken language supports are in place. This early sign exposure prevents delay in establishing language foundations and can then be used to provide a boost to the development of spoken language.

For more information:

Magnuson, M. (2000). Infants with congenital deafness: On the importance of early sign language acquisition. American Annals of the Deaf, 145(1), 6.

Tait, M., Lutman, M. E., & Robinson, K. (2000). Pre-implant measures of preverbal communicative behavior as predictors of cochlear implant outcomes in children. Ear and Hearing, 21(1), 18-24.

Yoshinaga‐Itano, C. (2003). From screening to early identification and intervention: Discovering predictors to successful outcomes for children with significant hearing loss. Journal of Deaf Studies and Deaf Education, 8, 11-30.

Yoshinaga‐Itano, C. (2006). Early identification, communication modality, and the development of speech and spoken language skills: Patterns and considerations. In P. Spencer and M. Marschark (Eds.), Advances in the spoken language development of deaf and hard-of-hearing children (pp. 298-327). New York: Oxford University Press.

Previous Listening Experience
Children who experience adventitious hearing loss (acquired hearing loss following the acquisition of language), as well as children who have had meaningful auditory experiences with a hearing aid before implantation, typically achieve high levels of spoken language outcomes with a cochlear implant. This relates to past imprinting or memory for this information. Children implanted beyond the early language learning years who have had limited listening experiences before implantation typically require more time and structured approaches to facilitating spoken language development and often do not achieve similar levels of receptive or expressive spoken language skills

For more information:

Nicholas, J. G., & Geers, A. E. (2006, June). Effects of early auditory experience on the spoken language of deaf children at 3 years of age. Ear and Hearing, 27(3), 286-298.

Cause of Hearing Loss
Some of the associated conditions arising from varying causes of hearing loss may influence the degree of benefit a child actualizes from a cochlear implant. For example, some children with hearing loss from cytomegalovirus have been observed to demonstrate auditory processing problems. Although a cochlear implant provides access to sound, it will not eliminate auditory processing problems related to interpretation of sound in the brain. Also, causes of hearing loss that affect the anatomy of the cochlea may present an obstacle to the insertion of all electrodes available through the cochlear implant which may then limit outcomes. For children with hearing loss from auditory neuropathy or auditory dys-synchrony, there appears to be varied benefit from a cochlear implant depending on where the dysfunction occurs in the auditory system. It is important that a complete battery of diagnostic evaluations be completed before proceeding with a cochlear implant so that families are clear on the appropriateness of a cochlear implant and varied outcomes for children with varying secondary conditions.

For more information:

Auditory Neuropathy—National Institute on Deafness and Other Communication Disorders

Gardner-Berry, K., Gibson, W., & Sanli, H. (2005, November). Pre-operative testing of patients with neuropathy or dys-synchrony. Emerging trends in cochlear implants. The Hearing Journal, 11, 24-25, 28, 30-31.

Pyman, B., Blamey, P., Lacy, P., Clark, G., & Dowell, R. (2000). The development of speech perception in children using cochlear implants: Effects of etiologic factors and delayed milestones. American Journal of Otology, 21, 57-61.

Additional Challenges
Increasing numbers of children with additional challenges are getting cochlear implants and demonstrating a range of outcomes. The type of additional challenge children demonstrate influences the outcomes they may obtain with their implants. For example, children with physical challenges may still demonstrate similar auditory development as their non-physically challenged peers with cochlear implants. However, if a child demonstrates other complex cognitive, language processing, or social communication challenges, these will affect outcomes related to the rate of spoken language development and the level of spoken language competence achieved. It is important that families and professionals do not expect that obtaining a cochlear implant will resolve these other challenges.

Although some children obtain their implants with known additional challenges, other children obtain their implants at young ages before other additional challenges become apparent (e.g., autistic spectrum disorder, learning disabilities). As it is not possible to predict when additional challenges may emerge that can directly affect performance outcomes, it is critical to closely monitor each child for possible complicating issues and to make necessary revisions and accommodations to approaches and strategies used as needed.

For more information:

Garber, A., & Nevins, M. E. (2007, July). Cochlear implants and special populations. HOPE Note. Retrieved March 9, 2011, from http://www.cochlearamericas.com/PDFs/HOPE_special_populations.pdf

Edwards, L. (2007). Children with cochlear implants and complex needs: A review of outcome research and psychological practice. Journal of Deaf Studies and Deaf Education, 12(3), 258-268.

Goldberg, D., & Perigo, C. (2006). Auditory learning and cochlear implantation for the young child with multiple disabilities. Audiology Online archived session, HOPE Online Library. Retrieved March 9, 2011, from http://www.audiologyonline.com/ceus/recordedcoursedetails.asp?cp_pid=6&class_id=5253www.cochlear.com/HOPE

Learning Styles
Some children are auditory learners; others are visual learners. Visual learners may benefit from visual context for learning through the use of visual reinforcement, for example, through books, videos, or diagrams. Auditory learners may benefit from strategies that provide auditory reinforcement, such as repetition of messages, listening to audiotapes, and repeating information aloud. A child’s learning style may affect implant outcomes as well as the choice of strategies used to achieve optimal outcomes. Some children may demonstrate more “auditory inclination” than others, with some readily learning auditory information without much guidance and others struggling for similar competence.

For more information:

Chute, P., & Nevins, M. E. (2006). School professionals working with children with cochlear implants. San Diego, CA: Plural Publishing.

Personality
All children have a unique personality that may influence how they function with their cochlear implant. A child’s assertiveness, positive attitude, resiliency, and ability to tolerate frustration are all integral to what outcomes may be actualized. If a child is shy and not willing to participate in activities to support auditory and speech development, this may affect spoken language and communication growth. If a child demonstrates resistant behaviors and is not willing to use the implant consistently, this will also affect optimal outcomes. Successful outcomes will be tied to a child’s motivation to use the implant and participate in activities to support auditory, speech, and spoken language development.

For more information:

Leigh, I. W., & Christiansen, J. B. (2009, April). Psychosocial aspects of cochlear implantation. Paper presented at Cochlear Implants and Sign Language: Building Foundations for Effective Educational Practices conference, Gallaudet University, Washington, DC.

Preisler, G., Tvingstedt, A., & Ahlström, M. (2002). A psychosocial follow-up study of deaf preschool children using cochlear implants. Child: Care, Health and Development, 28(5), 403-418. doi:10.1046/j.1365-2214.2002.00291.x

Priesler, G., Tvingstedt, A.L., & Ahlstrom, M. (2005). Interviews with deaf children about their experiences using cochlear implants. American Annals of the Deaf, 150(3), 260-267.

Factors Related to the Environment

Family Support

Children demonstrating the best outcomes with a cochlear implant (regardless of the other factors discussed) have strong family involvement and support. As expected, families who are integrally involved in providing a rich listening and language learning environment and helping a child to receive all of the necessary supports to maximize benefit from his or her implant will have a positive impact on outcomes.

For more information:

Moeller, M. P. (2000). Intervention and language development in children who are deaf and hard of hearing. Pediatrics, 106, E43.

Spencer, P. (2004). Individual differences in language performance after cochlear implantation at one to three years of age: Child, family, and linguistic factors. Journal of Deaf Studies and Deaf Education, 9, 395-412.

Use of More Than One Language
There are children with cochlear implants from homes that are multilingual and multicultural. Some families speak English and another language fluently, some are learning English as a new language, and some use a visual language such as ASL. Multilingual/multicultural factors will have an impact on the spoken language outcomes of a child with a cochlear implant. For children in this situation, it is necessary to identify and apply strategies and techniques in bilingual language learning based on which will be most effective for each child in relation to how language is used in the home

The factors that appear to predict the best outcomes for bilingual spoken language development for a child with a cochlear implant are: 1) two spoken languages used in the home, 2) early age of implantation (before age 2), 3) strong speech perception skills, 4) absence of additional disabilities, 5) intact language learning ability for the language of the home, 6) parent involvement, 7) motivation for bilingual learning, and 8) opportunities to use both languages in meaningful contexts with native users. (McConkey Robbins, 2007). For children who come from families in which ASL is the language used in the home, strong language foundations in ASL coupled with ongoing implementation of strategies to address the development and use of spoken English will positively affect spoken language outcomes

For more information:

American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists and audiologist to provide culturally and linguistically appropriate services. ASHA Supplement, 24, 152-158.

Grosjean, F. (2008). The bilingualism and biculturalism of the Deaf. Studying bilinguals. Oxford: Oxford University Press.

McConkey Robbins, A. (2007). Clinical management of bilingual families and children with cochlear implants. Loud & Clear! Retrieved March 9, 2011, from www.advancedbionics.com/content/dam/ab/Global/en_ce/documents/libraries/SupportLibrary/Newsletters/Loud%20and%20Clear/Clinical%20Management%20of%20Bilingual%20Families.pdf

Nevins, M. E., & Garber, A. (2010, December). Children from homes with spoken languages other than English. HOPE Bulletin. Retrieved from http://hope.cochlearamericas.com/sites/default/files/resources/FUN795_Children%20from%20Homes%20with%20Spoken%20Languages%20Other%20Than%20English.pdf

Teaching Children with CIs to Speak More than One Language

Thordardottir, E. (2006, August). Language intervention from a bilingual mindset. The ASHA Leader, 11(10), 6-7, 20-21.

Spoken Language Use in the Child’s Environment.
Children with cochlear implants may be in diverse educational environments using a variety of communication approaches. Regardless of program type and methodology, success with an implant will be positively impacted by the consistency and quality of spoken language use that is employed in a child's program. Determining the most effective strategies to address use of spoken language for each child should be individualized and based on the language and communication functioning of the child. (See the module on Language and Communication Planning.)

Factors Related to Cochlear Implant Technology

How Current is the Technology

Performance outcomes may vary depending on issues specific to the generation of the technology the child is using. Children implanted with more current technology may possibly demonstrate increased potential in comparison to children implanted with earlier technologies with less sophisticated speech processing capabilities.

Monitoring of the Speech Processor

Maintaining an appropriate individualized program on the child's speech processor, sometimes referred to as a ‘map' is critical to optimal spoken language outcomes. As the brain adjusts to sound over time, what may have at first been comfortable and "loud enough" without continued monitoring and updating of the speech processor may become insufficient and "not enough." This acclimation to sound may be clearly apparent or can sometimes go unnoticed, similar to a light on a dimmer that grows dim so slowly as to almost be imperceptible until it becomes too dark. A child may also inadvertently have electrodes that have been set for too much stimulation, causing discomfort. If this occurs and is not remedied, the child may see listening as a negative experience and may resist using the cochlear implant. If a child is functioning with an inadequate program, this can negatively impact progress with the implant. It is therefore imperative that the continued appropriateness of a child's speech processing program be closely followed to ensure optimal benefit. This requires daily close monitoring of the implant at home and at school and support by the hospital implant center. (See the module on Training the Ear to Listen—How to Check the Speech Processor.)

Bilateral Cochlear Implants
Increasing numbers of children are obtaining bilateral cochlear implants. The long-term spoken language benefits will be individual to each child. While the research related to the long-range benefit of bilateral implantation in regard to spoken language outcomes is still in its early stages, use of bilateral implants has been found to positively affect performance outcomes in relation to enhanced ease of listening and sound localization. When bilateral implantation is considered, there are still many things to think about related to whether the second implant should be completed simultaneously with the first implant or sequentially at a later time. There are also considerations for implanting the second ear related to the duration of deafness in that ear. (See the module on Considerations in the Implant Process.)

For more information:

Boystown National Research Hospital: Bilateral Cochlear Implants

Litovsky, R. (2010, February). Bilateral cochlear implants: Are two ears better than one? The ASHA Leader. Retrieved, July 2011, from http://www.asha.org/Publications/leader/2010/100216/BilateralCochlearImplants.htm

Litovsky, R. Y., Johnstone, P. M., Godar, S., Agrawal, S., Parkinson, A., Peters, R., et al. (2006). Bilateral cochlear implants in children: Localization acuity measured with minimum audible angle. Ear Hear, 27(1), 43-59.

Peters, R. (2006, January). Rationale for bilateral cochlear implantation in children and adults. Retrieved from http://www.cochlearamericas.com/PDFs/bilateral_white_paper.pdf

Consistency of Usage
The cochlear implant must be used consistently if a child is going to demonstrate ongoing progress with the implant. If periods of time pass without implant stimulation, children may not demonstrate expected progress with their implant.

Summary
While it is never possible to predict how any one child will do with a cochlear implant, children who demonstrate the greatest ease in developing spoken language and attain higher levels of spoken language outcomes appear to be most related to:

  • early identification of hearing loss followed by early amplification, language stimulation (spoken or signed language), and early implantation;
  • good prior listening experience and speech perception skills (for later-implanted students);
  • at least average cognitive skills and good attention skills; and
  • home and school environments that provide extensive exposure to spoken language.

Revised May 2012