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Background and Educational Characteristics of Prelingually Deaf Children Implanted by Five Years of Age

Geers, Ann; Brenner, Chris

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doi: 10.1097/01.AUD.0000051685.19171.BD
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Children who receive a cochlear implant by 5 yr of age are presented with auditory information at a crucial time for speech and language development. Children vary in the amount of speech information they obtain from a cochlear implant. The extent to which a child will use the auditory information provided by the implant to achieve speech, language, and reading competence is affected by characteristics that the child brings to the learning environment, characteristics of the family that affect the child’s learning and characteristics of the child’s rehabilitation program. This article examines these factors for a representative sample of children who were implanted at an early age between 1990 and 1996.

Child Characteristics

Child characteristics that could potentially affect performance with an implant include factors such as gender, age at onset of deafness, duration of auditory deprivation, etiology of hearing loss, age at diagnosis, age at implant, preimplant residual hearing, duration of implant use and the presence of other disabilities.

Gender

In normally developing children, it has been documented that girls exhibit a verbal advantage over boys, especially in early vocabulary development (Fenson, Pethick, Renda, Cox, Dale, & Reznick, 2000). This advantage is also apparent in female children with hearing impairment who are learning oral language (Easterbrooks & O’Rourke, 2001). These gender differences might be expected to affect a child’s speech and language progress after implantation.

Age at Onset

A number of studies have documented that children with later onset of deafness and a shorter period of auditory deprivation before implantation have better speech perception skills than children with early onset (Fryauf-Bertschy, Tyler, Kelsay, & Gantz, 1992;Osberger, Todd, Berry, Robbins, & Miyamoto, 1991;Sarant, Blamey, Dowell, Clark, & Gibson 2001;Staller, Beiter, Brimacombe, Mecklenberg, & Arndt, 1991;Tyler, Gantz, Woodworth, Fryauf-Bertschy, & Kelsay, 1997). However, when only those children with prelingual deafness (i.e., onset < 3 yr of age) are considered, age at onset of deafness was no longer a significant predictor of postimplant performance (Miyamoto, Osberger, Robbins, Myers, & Kessler, 1993;Osberger et al., 1991). In fact, at least one study has found that congenitally deaf children perform significantly better than children with prelingually acquired deafness (Tyler, Fryauf-Bertschy, Kelsay, Gantz, Woodworth, & Parkinson, 1997).

Etiology

Pyman, Blamey, Lacy, Clark, and Dowell (2000) evaluated speech perception scores in relation to etiology of hearing loss for 75 consecutive cochlear implant patients who were under 5 yr of age. Results indicated that etiologic factors did not have a statistically significant effect on speech perception outcome. Studies of adult implant recipients have shown that those who lost hearing from meningitis obtain less speech perception benefit from an implant (Battmer, Gupta, Allum-Mecklenburg, & Lenarz, 1995;Dorman, Hannley, Dankowski, Smith, & McCandless, 1989). Some studies with children have shown a detrimental effect of early meningitis on postimplant scores (Isaacson, Hasenstab, & Wohl, 1996), and others have not (Sarant et al., 2001).

Age Identified/Aided

The age at which the child’s hearing loss is identified and he or she receives hearing aids may be an important indicator of the initiation of family training and attention to the hearing loss. Data reported by Yoshinaga-Itano, Sedey, Coulter, and Mehl (1998) demonstrate the importance of identification and intervention before 6 mo of age to language development in young children with congenital hearing loss, regardless of the degree of hearing loss. Therefore, it could be anticipated that children whose hearing loss was identified at a young age might exhibit an advantage in their response to a cochlear implant.

Age at Implant

An advantage for early implantation is most apparent when it occurs before the child turns 5 yr of age. Fryauf-Bertschy, Tyler, Kelsay, Gantz, and Woodworth (1997) found better open-set word recognition scores postimplant for children implanted before age 5 compared with children implanted after age 5. Kirk and Hill-Brown (1985) and Tye-Murray and Kirk (1993) found greater speech production improvements in children implanted under 5 yr of age. Connor, Hieber, Arts, and Zwolan (2000) documented higher speech and language scores in children implanted during preschool compared with those implanted during the elementary years. Data on children who received an implant in infancy (18 mo and younger) indicate normal language acquisition and significantly better speech perception, speech intelligibility and spoken language than children implanted somewhat later, between 19 and 30 mo (Hammes, Novak, Rotz, Willis, & Edmondson, 2002).

Preimplant Residual Hearing

Increased auditory experience before implantation may facilitate the development of speech perception skills postimplant. In particular, the preoperative presence of open set speech recognition is a significant predictor of postimplant speech perception skills (Zwolan, Zimmerman-Phillips, Ashbaugh, Hieber, Kileny, & Telian, 1997). However, preimplant thresholds have been found unrelated to postimplant speech perception scores (Tyler, Fryauf-Bertschy, Gantz, Kelsay & Woodworth, 1997).

Duration of Implant Use

Prior research has indicated that scores on speech perception, speech production and language measures improve with increased implant experience. Speech perception shows substantial growth for the first 2 to 3 yr of device use (Fryauf-Bertschy et al., 1997;Geers & Brenner, 1994;Miyamoto et al., 1994;Quittner & Steck, 1991) Likewise, speech production improvement has been document over at least 3 yr (Tobey, Geers, & Brenner, 1994). Svirsky, Robbins, Kirk, Pisoni, and Miyamoto (2000) as well as Tomblin, Spencer, Flock, Tyler, and Gantz (1999) demonstrated that the longer children use implants the better their language. Evidence for the effects of duration of use on language are strongest over the first 2 to 3 yr of implant use. Further gains at intervals after 2 yr were smaller (Tomblin et al., 1999).

Multiple Handicaps

There is evidence that some additional handicapping conditions interfere with auditory development after implantation. Pyman et al. (2000) found that children with motor and/or cognitive delays were significantly slower than other children in the development of speech perception skills after implantation. Lesinski, Hartrampf, and Dahm (1995) reported on the successful cochlear implant stimulation and programming of 47 children with one or more handicaps in addition to deafness. Handicaps that were considered to have an effect on postoperative outcome included mental retardation, autism, cerebral palsy, and a variety of genetic syndromes. Isaacson et al. (1996) compared matched groups of implanted children with and without learning disability. Children with learning disability progressed more slowly and had poorer auditory perception and linguistic competence. Waltzman, Scalchunes, and Cohen (2000) measured speech perception postimplant in 29 children with documented impairment(s) in addition to deafness. As a group, these children received significant benefit from cochlear implantation, but with slower progress than for children with hearing loss as their only problem.

Family Characteristics

Effects of family characteristics on the speech and language skill development of children with cochlear implants are not well documented. However, there is evidence that children with hearing impairments whose families seek cochlear implants are not significantly different from children with hearing impairments whose parents are not seeking a cochlear implant (Knutson, Boyd, Goldman, & Sullivan, 1997). Therefore, the effects of family characteristics on the larger population of children with hearing loss should mirror those observed in children with implants. Characteristics that have been examined include hearing status, ethnicity, family intactness, socio-economic status, and communication mode used in the home.

Hearing Status

Some studies indicate that deaf children of hearing-impaired parents exhibit higher levels of reading achievement than deaf children of hearing parents, presumably because of their early exposure to sign language (see Kampfe & Turecheck [1987] for a review of these studies). However, because relatively few hearing-impaired parents choose cochlear implantation for their children, it has not been possible to document the contribution of parental hearing status to postimplant outcome.

Ethnicity

Cohen, Fischgrund, and Redding (1990) reviewed studies indicating that deaf children from ethnic, linguistic and racial minority backgrounds demonstrate significantly depressed achievement levels relative to their white deaf peers. Another study by Mapp and Hudson (1997) revealed that racial and ethnic group membership was significantly related to parents of deaf children’s use of successful coping strategies.

Intactness

Calderon and Low (1998) examined the social-emotional, language and academic development in children with hearing loss with and without fathers. Results indicated that children whose father was present had significantly better academic and language outcomes than those without a father present.

Socio-Economic Status

Family factors associated with development of spoken language by children with hearing loss enrolled in auditory-verbal therapy were examined by Easterbrooks, O’Rourke, and Todd (2000). The most successful were from affluent families with more females than expected. Musselman, Wilson, and Lindsay (1989) studied family characteristics of children enrolled in various types of preschool programs. Children in auditory verbal individual programs had the most hearing, highest intelligence and most favorable socio-economic profile, followed by children in oral classes, TC individual programs, and TC classes. Scores on measures of spoken language followed the same pattern.

Educational Support

Parents’ involvement in the child’s therapy and educational program has been cited as essential to the child’s linguistic development postimplant (Bertram & Pad, 1995;Cohen & Waltzman, 1995). In fact, parent participation in the child’s rehabilitation program is considered by many multidisciplinary implant teams to be a prerequisite for implant candidacy.

Communication Mode

Although some studies have reported evidence that early use of manual English may have positive relationship to early language and reading development, others indicate no such relationship (Kampfe & Turecheck, 1987). Mapp and Hudson (1997) examined the effect of family factors on measures of stress and coping with deafness. Use of a sign communication mode was associated with reduced stress. Desselle (1994) examined relationships among family communication modes and measures of self-esteem. Parents who used total communication (speech, fingerspelling, and sign) had children whose self-esteem scores were higher than those of children whose parents use an oral-only method of communication (speech). Also, a positive relationship was found between student self-esteem and reading level.

Together, these results suggest that postimplant outcomes will be positively associated with higher socio-economic status, majority ethnicity, intact families who actively participate in the child’s rehabilitation program. They also suggest some advantage for children whose families use sign language.

Educational Characteristics

Educational choices that have been discussed in terms of their importance for deaf children include mainstream or special education class placement, oral or total communication mode and a desirable amount of individual therapy.

Class Placement

Children with hearing loss placed in integrated classes have tended to be those with hearing losses less than 90 dB or postlingually hearing-impaired. They outperform nonintegrated hearing-impaired students on English language and reading tests even when degree of hearing impairment and age at onset variables are controlled. However, as a group, they exhibit academic delay in comparison to their normally hearing peers. Most mainstreamed severely-profoundly hearing-impaired students are integrated for only a portion of the school day (Geers, 1990).

Communication Mode

One educational variable frequently examined in relation to implant benefit is the communication mode used in the child’s classroom. This variable is most often dichotomized into oral communication (OC) approaches and total communication (TC) approaches. Proponents of the OC approach maintain that dependence on speech and audition for communication is critical for achieving maximum auditory benefit from any sensory aid. Constant use of auditory input to monitor speech production and to comprehend spoken language provides the concentrated practice needed for optimum benefit from a cochlear implant. Types of OC approaches differ in their emphasis on the auditory and visual channels for the reception of spoken language. Methods range from the cued speech approach, in which manual cues are used to complement lipreading, to the auditory-verbal approach in which lipreading is discouraged and the child is taught from an early age to make use of whatever auditory information is available through his or her sensory device to understand speech.

Proponents of the TC approach maintain that the child with severe-profound deafness benefits most when some form of manually coded English accompanies speech. The use of a sign system allows for easier assimilation of language through the unimpaired visual modality. The child is then able to associate what he or she hears through the implant with signed representations of language to support spoken language development. In practice, TC programs range from those that rely heavily on signed input with less emphasis on speech and English syntax to those that emphasize speech, audition, and lipreading and maintain careful adherence to English syntax and morphology. Although there is evidence that children enrolled in OC programs demonstrate better speech perception, speech production and language improvement postimplant than those in TC programs (Geers, 2002;Miyamoto, Kirk, Svirsky, & Sehgal, 1999;Tobey et al., 2000), other studies indicate greater vocabulary improvement for children enrolled in TC programs (Connor et al., 2000;Robbins, Svirsky, & Kirk, 1997).

Individual Therapy

Educators recommend one-to-one training for 1 to 1.5 hr per week to optimize a child’s ability to interpret the auditory information provided by the cochlear implant (Dawson, Blamey, Dettman, Barker & Clark, 1995;Dettman et al., 1996). Tye-Murray (1992) suggests at least 10 to 15 minutes a day should be devoted to formal speech perception training. However, the relation between amount of therapy and outcome has not been documented.

Rationale

This study documents child, family and educational characteristics of a large representative sample of 8- to 9-yr-old prelingually deaf children who received cochlear implant surgery under 5 yr of age. Such data can provide clinicians and researchers with insight regarding the types of families who sought early cochlear implantation for their children and the types of educational settings in which these children were placed. It is apparent from the literature that factors such as the child’s age, gender, age at onset of deafness, at implant and at test, duration of implant use, family characteristics, and intelligence can have a substantial impact on test scores. These must be accounted for before the true impact of educational factors on performance with an implant can be determined. Parents and children with particular characteristics may be drawn to certain kinds of programs, and programs emphasizing spoken language may favor the admission of children with certain characteristics. Failure to control for any of these intervening variables may obscure the underlying causes of exceptionally good or poor performance with an implant (see Kirk [2000] for a discussion of these issues). It is important to undertake studies that control for as many of these factors as possible so that the relative benefits of specific educational approaches can be documented. Therefore, although the demographic and educational characteristics of these early implanted children have inherent descriptive value, they will be even more valuable as predictors of measured outcomes.

Method

A power analysis (Cohen, 1992;Cohen & Cohen, 1983) was conducted to determine the sample size adequate for detecting effects of substantive interest given the large number of variables entered into this analysis. A 0.05 level of significance (two tailed) was assumed and a minimum power of 0.80. The power analyses indicated that a sample size of 160 would be sufficient to detect the smallest of the effects of interest. In fact, with a sample size of 160, most effects would be tested with a power of at least 0.90.

Participants were selected to be as homogeneous as possible on factors that were believed to affect performance postimplant. The following child and family characteristics were included as sample selection criteria:

  1. Chronological age at time of data collection between 8 yr 0 mo and 9 yr 11 mo
  2. Age at onset of deafness at or before 36 mo
  3. Implanted by age 5
  4. No diagnosis of additional educationally significant disabilities (e.g., mental retardation, autism, learning disability)
  5. Monolingual English-speaking home environment

Centers that had implanted children who met the age criteria described in items 1 to 3 were identified by the staff at Cochlear Corporation from their database of patient characteristics. Each of these Centers was mailed an information packet about the study to share with the families of the identified children who met criteria 4 and 5. This packet contained a postcard that families could return to the Center for Applied Research on Childhood Deafness at Central Institute for the Deaf if they were interested in receiving an application form for the study. Each accepted family was invited to come to St. Louis to attend a Cochlear Implant Summer Research Camp. Expenses were paid for the child and one parent, including transportation, hotel accommodations for 4 nights and daily entertainment activities. A total of 255 applications were received over the 5-yr period between 1996 and 2000. These applications were processed as follows:

  • 28 Ineligible—did not meet one or more of the selection criteria
  • 16 Accepted but family declined to attend
  • 15 Accepted for 1996 pilot data collection camp
  • 47 Accepted for 1997 data collection camps
  • 45 Accepted for 1998 data collection camps
  • 44 Accepted for 1999 data collection camps
  • 45 Accepted for 2000 data collection camps
  • 15 Declined after subject limit reached

A pilot sample of 15 children was tested in the summer of 1996 and results were used to finalize the test battery. Then, over a 4-yr period, 181 children from 33 different states and five Canadian provinces were administered the final battery. These children were implanted between 1990 and 1996, with the majority (72%) receiving their surgery in 1992, 1993 and 1994. Data obtained from the Cochlear Corporation records search revealed that there were approximately 500 children with cochlear implants who turned 8 or 9 yr old each year between 1997 and 2000. Approximately half of these had been implanted before their 5th birthday. This sample included about 18% of the total population and is considered to be a representative sampling of children with these characteristics. The geographical distribution of the participants’ homes is depicted in Figure 1. The sample includes deaf children from across the US and Canada and is not heavily represented by any one geographical region.

Figure 1
Figure 1:
Geographical distribution of home states/provinces of study participants with darkest shading for states with more than five participants and lighter shading for states with fewer than five. Key indicates number of states/provinces in each frequency category.

Approximately 15 children, accompanied by a parent, were included in each data collection camp session. Testing took place 2 hr each day for 3 days. All children were tested under similar conditions with a consistent group of examiners on an identical battery of tests. Children were tested individually in their hotel rooms, which were converted to testing suites each morning. The parents attended educational seminars during this time and completed questionnaires and signed release forms for questionnaires sent to implant centers and clinicians. In the afternoon, families participated in planned recreational activities.

Results

A wide range of variables were examined and quantified for the participating children. These variables were categorized as child characteristics, family characteristics, and educational characteristics as listed in Table 1.

TABLE 1
TABLE 1:
Descriptive variables.

Child Characteristics

Basic descriptive data are summarized in Table 2. The group of 181 participants contained an equal representation of genders (90 boys and 91 girls). This study sought to control for the effects of maturation on outcome measures by testing children within a 2-yr age span. The sample was divided equally between 8 yr olds (N = 93) and 9 yr olds (N = 88). Children this age were selected because they are old enough to have substantial experience using a cochlear implant from an early age. Furthermore, they are old enough to take standardized speech, language and reading tests. Testing children at about the same age was considered essential to the design of this study. Children’s scores on most measures improve as they gain experience with the world around them and progress in school. When a sample includes children of widely different ages, it is necessary to correct for the effects of maturation before attributing subject differences to other variables of interest.

TABLE 2
TABLE 2:
Child characteristics (ages given in years-months).

Age at onset of deafness was also restricted through sample selection criteria to children with prelingual deafness (i.e., before age 3). Although the majority of the children (N = 140) were reportedly deaf from birth, 15 became deaf under 1 yr of age, 18 when they were 1 yr old, and eight when they were 2 yr old. The length of auditory deprivation (length of time between onset of deafness and receiving an implant) ranged from 5 mo to 5 yr 4 mo with an average deprivation of 3 yr 1 mo.

Etiology of Hearing Loss was most often reported as unknown (90 cases). Thirty-five families reported that the hearing loss was caused by a known genetic condition. Thirty-two children were deafened by meningitis, 13 reported maternal CMV, seven were reported to have become deaf after experiencing a high fever (six cases) or being administered an ototoxic drug (one case), and four children had problems at birth (two of these were premature with low birthweight).

This group of children was characterized by early identification and amplification. Since the diagnosis of hearing loss, hearing aid fitting and educational intervention occurred within 2 mo of each other for the vast majority of children, all of these factors are represented by age at hearing aid fitting. Children were first aided, on average, at 1 yr, 3 mo of age, ranging from as young as 1 mo to as late as 36 mo of age. Of the 140 participants who were deaf at birth, only 15 received intervention by 6 mo of age, the critical period according to the data reported by Yoshinaga-Itano et al. (1998). Forty of the children who were deaf from birth were aided between 6 and 12 mo, 70 at 1 yr of age, and 15 at age 2.

Sample selection criteria specified that the child receive their implant by 5 yr of age. Restricting the sample in this way permitted examination of the effects of very early implantation on speech and language development. In fact, most of the children were implanted before their 5th birthday. Three children received an implant just before their 2nd birthday, 60 children were implanted at age 2, 72 at age 3, 37 at age 4, and nine at age 5. Duration of implant use was controlled by subject selection criteria that specified age at implant (before 5 yr) and age at test (8 or 9 yr). Therefore, the vast majority of the sample had at least 4, but not more than 6 yr of use. This selection criterion controls for variability associated with the first 3 yr of device use.

Although the subject selection criteria specified that no participant have been diagnosed with educationally significant additional handicaps, administration of the Wechsler Intelligence Scale for Children–Performance Scale (Wechsler, 1991) at the time of testing resulted in IQ scores below 85 for 24 of the children. Scores in this range are generally considered below average. However, only nine of the children obtained Performance IQ scores below 80, which could be considered indicative of educationally significant retardation. Average subtest scaled scores on the WISC-III Performance Scale were within the average range for hearing children (M = 10; SD = 3) for all subtests: Picture Completion (M = 10.6; SD = 2.7), Picture Arrangement (M = 10.1; SD = 3.5), Block Design (M = 11.2; SD = 3.5), Coding (M = 8.9; SD = 3.1), and Object Assembly (M = 10.5; SD = 2.7).

At the time these children were implanted it was required that the child complete a trial period of at least 6 mo with a hearing aid and demonstrate no open set speech perception before receiving a cochlear implant. Therefore it was assumed that none of the children demonstrated significant amounts of preimplant residual hearing.

Family Characteristics

The sample selection criteria specified that all of the families of children enrolled in this study use English exclusively at home. All but two children had parents with normal hearing (one child had two prelingually deaf parents and another child had a postlingually hearing-impaired mother). Most of them (162) listed ethnicity as white. Minority groups represented included five African-American, five Hispanic, five Asian, and four other.

The median family size was four members and ranged from two to seven members. Twenty-nine of the participants were only-children at the time of the study. Seventy of the children were being raised in two-parent families with two children. Seventy-seven were from families with more than two children. Seventeen of the children were from single parent families. One hundred seventy-six children had a mother living at home, and 165 children had a father living at home. The median family income was between $50,000 and $65,000, with 53 families making more than $80,000 per year. All but two families had at least one high school graduate as a parent. One hundred fifteen of the children had at least one college graduate as a parent (88 mothers and 93 fathers reported having a college degree).

Parents completed a questionnaire describing the frequency with which the hearing-impaired child participated in various out of school and family activities (e.g., shopping, family outings, reading with a parent). Responses were judged on a 5-point scale from “often” to “never.” The distribution of responses is summarized in the Appendix. Over 90% of the families’ responses indicated including the child in the listed activities on a regular basis.

These data indicate that families seeking a cochlear implant for their child, especially during the initial period of device availability, tended to have normal hearing, be of majority (white) ethnicity and have more education and higher incomes than the general population. The families tended to be intact with both a mother and a father who involved their hearing-impaired child in family activities on a regular basis.

Educational Characteristics

Each of the educational variables was measured over five rating periods: preimplant, first year post, 2nd year post, 3rd year post, and current year. Parents completed a questionnaire in which they read descriptions of educational methods and class settings and reported their child’s placement each year of the rating period.

To capture the continuum of communication modes, this study used a rating scale that was intended to reflect the amount of emphasis on speech and auditory skill development provided in the child’s classroom. Classroom communication mode was assessed with a rating scale completed by the parents. A rank between 1 and 6 was assigned to each instructional mode for each of the five rating periods. Ratings between 1 and 3 were assigned to TC programs. In mostly sign programs (1) sign-only was used for communication during some of each day. In speech and sign programs (2) speech almost always occurred simultaneously with each signed word and sign-only or speech-only were rarely used. In speech emphasis programs (3) speech-only was used for communication during some of each day. Ratings between 4 and 6 were applied to oral communication programs, where sign language was never used. In cued speech programs (4) a formal system of manual cues (Cornett, 1967) was used to facilitate lipreading. In auditory-oral programs (5) the child was encouraged throughout the day to both lipread and listen to the talker. In auditory-verbal (6) programs the child was taught to rely on listening alone to understand speech.

Although the participants were not selected based on communication mode, there were roughly an equal number from oral and from total communication settings. Change in classroom communication mode over time is depicted in Table 3, where the number of children with each mode rating is presented for each of the five rating periods. The number of children enrolled in TC or oral classrooms did not change much over the 5 yr. The number of children in TC classrooms decreased slightly from 89 preimplant to 83 during the year just completed and the number in oral classrooms increased slightly from 92 to 98. However, within each communication method, there was an increasing emphasis on speech and audition with greater duration of device use. The number of children enrolled in TC classrooms with a sign emphasis decreased from 26 preimplant to four during the year just completed, whereas enrollment in TC programs with a speech emphasis increased from 17 to 35 children over the same time period. The number of children using an auditory verbal approach increased from 33 preimplant to 42 during the year just completed. Classroom communication mode scores for individual children are depicted in Figure 2, where the mode rating has been averaged across the five rating periods. The 92 children with average scores of 4 or higher had spent most of their years in an oral setting. The 89 children with average mode scores below 4 had spent most of their years in a total communication setting.

TABLE 3
TABLE 3:
Communication mode frequency by year.
Figure 2
Figure 2:
Classroom communication mode rating averaged for preimplant and 4 postimplant years is plotted in ascending order for each of the 181 participants. Ratings between 1 and 3 indicate total communication modes, and those between 4 and 6 indicate oral placements.

Parents were asked to describe the type of school setting in which their child was enrolled each year of the rating period. Results are summarized in Figure 3. Parents reported school placement as none, public, private or both public and private. There was an increase in the percentage of children enrolled in public school placement over time from less than half preimplant to almost 80% four or more years after implantation. Parents also reported classroom placement each year as full time special education for children enrolled exclusively in a self-contained classroom, partial mainstreaming for children who spent the day with both hearing-impaired and normal-hearing children and full mainstreaming for children who spent their entire school day with normal-hearing children. The percentage of children either partially or full mainstreamed increased from 25% at the time of implant to 71% after 3 yr to 83% at the time of the study. This finding is consistent with results reported by Francis, Koch, Wyatt, and Niparko (1999), which showed an increase in mainstream classroom placement with length of cochlear implant experience, which resulted in a savings ranging from $30,000 to $200,000 in educational costs.

Figure 3
Figure 3:
Participant enrollment at the time of implant and for each of 4 postimplant years is plotted for (A) public and private school placement and (B) special education and mainstream class placement.

Speech/language therapy was assessed retrospectively by questioning the clinicians who provided the intervention. Parents identified all clinicians who saw their child for individual or small group speech and/or auditory training (outside of classroom instruction) since receiving the implant. A questionnaire was mailed to each clinician. Return-rate on questionnaires after follow-up phone calls to nonrespondents was 87%. Clinicians reported the services provided during the first, second, and third years postimplant and during the school year just completed. The following variables were calculated based on responses to these questionnaires:

  1. Amount of therapy: Each clinician reported the number of weeks, hours per week, and size of the therapy group in which the child was seen for speech/language intervention. The amount of therapy was quantified each year as the number of weeks per year times the number of hours per week divided by the size of the group. These children averaged 1.5 hours per week of individual therapy each year postimplant. Unlike results reported by Francis et al. (1999), there was no significant decrease in hours of therapy provided with duration of implant use.
  2. Clinician experience: Each clinician assigned a rating between 1 and 4 based on the number of deaf children previously treated (none, 1 to 4, 5 to 10, and greater than 10). That rating was doubled if the clinician reported previously working with an implanted deaf child. Results are summarized by year in Figure 4. Half of the therapists reported that they had experience teaching more than 10 deaf children, including those with implants.
  3. Figure 4
    Figure 4:
    Percent of clinicians with and without experience working with implanted children in relation to number of deaf children treated before the rated child.
  4. Use of signs: Each clinician assigned a rating between 1 and 3 based on whether they never, sometimes, or usually used signs in therapy. Results are summarized by year in Table 4. Although roughly half of the children used sign language in their classroom, relatively few had clinicians who signed. Some decrease in sign use with increasing implant experience was observed. During the first year postimplant 24% of clinicians reported that they usually used sign with the implanted child. This proportion had decreased to 15% by the current year.
  5. TABLE 4
    TABLE 4:
    Percent use of signs or manual cues in therapy.
  6. Use of cues: Each clinician assigned a rating between 1 and 3 based on whether they never, sometimes or usually used cued speech. Results are summarized by year in Table 4. Relatively few clinicians reported using cued speech at any time, and for those who did so, little change in their use of cued speech over time was observed.

The final educational variable quantified was Parent Participation in Therapy. Parents rated the frequency with which they participated in the child’s therapy during the first, second, and third years postimplant as well as the year just completed. 26 items describing intervention activities typically recommended to parents were listed and the parent indicated whether they did this daily, weekly, monthly, rarely or never. These ratings were averaged over the 26 items for each year. On average, parents reported that they worked with their child daily for the first 2 yr postimplant, and between daily and weekly for the third year post and the year just completed.

Relations Among Child, Family, and Educational Variables

Table 5 is the intercorrelation matrix describing the relations among child, family and educational characteristics of this group of children. In general, these variables were relatively independent of one another. Age at onset of deafness was significantly positively correlated with age first aided, age at implant was significantly positively correlated with age at test and negatively correlated with duration of implant use. Communication mode was positively correlated with school setting (oral children were more likely from private schools), IQ (higher IQ was associated with greater speech emphasis), therapy hours (more therapy was associated with greater speech emphasis) and negatively correlated with the use of signs in therapy. Clinicians who used signs tended to be from public rather than private school settings and children with the greatest number of hours of therapy also tended to have the most experienced clinicians.

TABLE 5
TABLE 5:
Intercorrelation matrix.

Summary

This article has described the child, family, and educational characteristics of a group of 181 children whose postimplant performance will be analyzed in the subsequent articles in this supplement. These children were selected to be homogeneous on a number of factors. All of the children were 8 to 9 yr old, had lost their hearing before 3 yr of age and had no diagnosis of additional handicapping conditions. All of the children had the benefit of early cochlear implantation before or shortly after their 5th birthday.

Children with these characteristics who received cochlear implants were advantaged in many respects. Most of them had average to above average intelligence and came from intact middle to upper-middle class families with both parents in the home. All families were English speaking and all but two families had normal-hearing parents. Parents reported that they included their hearing-impaired child in family activities on a frequent basis and actively participated in the child’s therapy and school program.

Educational characteristics indicate that children with implants are enrolled in the full range of educational placements available across the United States and Canada. Fairly even distributions of children from public and private schools, special education and mainstream classes, and oral and TC methodologies were represented. However, within the TC method, few children had an emphasis on sign language, with most programs giving speech an equal or greater emphasis. Within the Oral method, few children were enrolled in programs that used cued speech. Children varied in the amount of speech and language therapy they received and the experience of their clinicians. Over half of the clinicians had prior experience with deaf children and children with implants. Retrospective analysis indicated that educational placement changed as children gained increased experience with a cochlear implant. Children were rated as receiving an increased emphasis on speech and auditory skills in their classroom setting and they tended to move from private school and special education settings to public school and mainstream programs. These results are consistent with the conclusion that early cochlear implantation is an extremely cost effective procedure that allows deaf children to participate in a normal school environment with hearing age mates.

Acknowledgments:

This study was supported by Grant No. DC03100 from the National Institute on Deafness and other Communication Disorders (NIDCD) of the National Institutes of Health to Central Institute for the Deaf (CID). We gratefully acknowledge the families of children with implants from across the USA and Canada who enthusiastically participated in this study as well as the staff of Cochlear Corporation and implant centers across the USA and Canada for their role in disseminating information about the study to potential participants. Michael J. Strube, Professor of Psychology at Washington University conceived and conducted the multivariate approach to data analysis. Christine Brenner, CID research associate, coordinated subject recruiting, testing and data preparation. Arnold Heidbreder, CID technical research scientist, coordinated equipment selection, set-up and maintenance. Camp counselors included CID teachers LaShawn Cole, Sarah Fessenden, Heidi Geers, and Dawn Selover, along with CID research assistants Gina Torretta and Michelle Baird. Guest lecturers for the parent education program included Debbie Carter, Lisa Davidson, Victoria Kozak, Nancy Tye-Murray, and Patricia Wasserman. Psychometricians who administered the Wechsler Intelligence Scale were Abbie Sterling from Special School District of St. Louis County and Pamela Zacher from Central Institute for the Deaf. Pam Farney from the Special School District of St. Louis County provided cued speech transliteration. Jean Moog, Head of the Moog Center for Deaf Education, inspired this project and, together with Ann Geers was responsible for its inception.

Appendix

Home activities questionnaire.

TABLE

Table
Table:
Estimate the frequency of your child’s involvement in these home activities. Rate the activity as occurring “often” (1) if your child engages in this activity more than once a week. Rate the activity as “never” (5) if this is not an activity in which your child engages. With these extremes in mind, indicate the point on the scale that best represents the frequency with which your child engages in each activity.

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