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Assessing Joint Attention and Symbolic Play in Children With Cochlear Implants and Multiple Disabilities: Two Case Studies

Johnson, Karen C.*; DesJardin, Jean L.*; Barker, David H.; Quittner, Alexandra L.; Winter, Margaret E.*

doi: 10.1097/mao.0b013e318162f1f3
Original Articles

Objective: The presence of disabilities in addition to deafness poses unique challenges for evaluating outcomes in young children who receive cochlear implants. We describe two cases in which measures of joint attention and symbolic play contributed to our understanding of progress in language acquisition following implantation for children with additional developmental disabilities.

Study Design: Prospective case study.

Setting: Tertiary referral center.

Patients: Case 1, identified with global developmental delays and implanted at age of 2 years 8 months; Case 2, diagnosed with autism spectrum disorder and implanted at age of 4 years 4 months.

Intervention: Cochlear implant.

Main Outcome Measure(s): Communication assessments were conducted using the Reynell Developmental Language Scales and the MacArthur-Bates Communicative Development Inventories before implantation (baseline) and at 12 months postimplant. Children were also videotaped during a 10-minute free play with their mothers (Joint Attention task) and 5-minute solitary play (Symbolic Play task) at baseline, 6 months, and 12 months postimplant. Videotapes were coded for child attention and play states.

Results: The MacArthur-Bates Communicative Development Inventories provided important information regarding both children's emerging joint attention and symbolic play skills that are typically not assessed by direct measures of early child language. Videotaped parent-child interaction revealed qualitative differences in the nature of these children's attention and play, which has important implications for intervention.

Conclusion: For these two children, obtaining developmental information from various sources, including precursor skills to the development of oral language, provided a more complete picture of each child than conventional clinician-elicited language assessments alone.

*House Ear Institute, Los Angeles, California; and †University of Miami, Miami, Florida, U.S.A.

Address correspondence and reprint requests to Karen C. Johnson, Ph.D., House Ear Institute, 2100 West Third St, 5th Floor, Los Angeles, CA 90057; E-mail:

© 2008 Otology & Neurotology, Inc.