Evaluation of the Reading and Writing Skills of Children with Cochlear Implants.
Hearing-impaired children follow the same semantic process when acquiring the same set of skills compared with their normal-hearing peers when their reading and writing skills are examined. However, owing to the insufficiency of the sound stimuli reaching the brain during the speech and language development, hearing loss can negatively affect both the reading and writing skills of hearing-impaired individuals [1, 2]. Meanwhile, the communication skills of children with hearing loss can be developed with the use of cochlear implants. Such implants have become popular among children with profound hearing loss, particularly those who do not benefit from conventional hearing aids. In primary school, both normal and hearing-impaired children are taught to read and write at the same time under the same educational curriculum. In such a system, hearing-impaired children are included in the same educational program within the same classrooms as their normal-hearing peers. However, when examining the classroom skills of hearing-impaired children, several differences in their reading and written expression skills can be found compared with their normal-hearing peers. For example, in comparison with their normal-hearing peers, hearing-impaired children use fewer words in their written narratives .
Cochlear implantation alone is not sufficient to facilitate the development of language and communication skills among hearing-impaired children. Rather, many other factors affect these skills. Some of these include diagnosis time of hearing loss, age upon first usage of hearing aids, history of special education/rehabilitation, training before and after using the device, family education, child's intelligence and memory levels, implantation age, and total usage time of the cochlear implant [4-6]. Furthermore, family income, maternal engagement, and residual hearing before implantation are important factors for accelerated language comprehension of students with cochlear implant . In the literature, the reading and writing skills of hearing-impaired students have been separately assessed, and only a few studies have examined the reading and writing skills of children together. Therefore, written language and paragraph reading comprehension ability for Mandarin-speaking children with cochlear implants were evaluated and compared with their normal-hearing peers [8, 9]. In addition, while past studies have assessed the reading and writing skills of hearing-impaired students using hearing aids, only few studies have evaluated the reading and writing skills of children using cochlear implants.
The aim of the present study is to evaluate the reading and writing skills of children using cochlear implants, particularly secondary school children of the 6th, 7th, and 8th grades, and to compare the reading and writing performances of children with implants and their normal-hearing peers. The second aim of the study is to examine the characteristics of students with cochlear implants, particularly those that have a significant impact on the reading and writing skills of students.
MATERIALS and METHODS
The research population comprised 20 students with normal-hearing ability and 20 hearing impaired students using cochlear implants. The students who participated in the research were 12-14 years old and enrolled during their 6th, 7th, and 8th grades. Hearing impaired students had prelingual bilateral severe to profound sensorineural hearing loss and have been using a unilateral cochlear implant for at least two years. All students with implants used hearing aids before implantation except for one. Students with hearing impairment have no additional physical/psychological disabilities other than being hearing-impaired.
The control group of the study comprised children with normal hearing in the same age group who have been going to the same classes (6th, 7th, and 8th grades) in normal primary schools. These children passed the Distortion Product Otoacoustic Emission test with no additional psychological/physiological disabilities.
The present study was approved by the institutional review board. A written informed consent form was obtained from the parents of the patients who participated in this study.
The Written Expression Proficiency Assessment Tool was used to evaluate the participants' writing skills , and the Informal Reading Inventory  was employed to assess reading skills as well. These tests have been verified in terms of their reliability and validity for research [10, 11].
First, for the evaluation of the writing ability of students, the Written Expression Proficiency Assessment Tool was used. Details about the aim of the study and its estimated duration were given to the students. To evaluate their writing skills, a picture about a traffic jam that was caused by a car with a flat tire in the traffic lights was shown to the students, and they were asked to write a story that was relevant to what they saw in this picture. Then, questions about the picture were asked, and the answers given were evaluated. They were allowed to take their time, that is, no time constraint was applied at this stage.
Later on, the students' written narratives were evaluated over 100 points using the Written Expression Skill Evaluation Form. According to this form, the title is expressed in 3 points, the expression level in 51 points, the narrative richness in 24 points, and the writing rules in 22 points.
In the second part, the Informal Reading Inventory was used for the evaluation of the reading ability of students. The inventory contains stories and informative texts appropriate for students from each grade level. It evaluates the reading ability by using two forms: Reading Assessment Form and Response Forms to Questions.
When the reading was finished, the student was asked talk about the story read to the researcher. Three main criteria were taken into consideration for evaluating the Reading Assessment Form: characters, main events, and details. The researcher evaluated this narration by giving 25 points for the characters, 50 points for the main events, and 25 points for the details of the story. Then, the students were asked to answer questions about the text through the Response Forms to Questions. There were 10 questions in the form and each question was scored with 10 points. The scores of the reading assessment and the Response Forms to Questions related to the text were added and averaged, and the total reading score was calculated.
Results for both the students with normal hearing and those with cochlear implants showed homogeneous distributions of total reading and writing scores. The independent samples t-test was used to obtain these results. The relationship between the reading and writing performances of students with normal hearing and cochlear implant was analyzed using the simple correlation method. The effects of implantation age and total time of implant use, which were thought to influence the levels of reading and writing performances, were analyzed by regression analysis. Statistical for Social Sciences version 15 (SPSS Inc.; Chicago, IL, USA) was used for the statistical analysis in the present study.
Table 1 shows the descriptive statistics for the total reading and writing scores of normal-hearing and students with implants. A significant relationship can be found between implanted and normal-hearing students in terms of their total reading scores [t (20.35) = -5.23, p<0.001, Cohen's d=1.75] and total writing scores [t (22.33) = -6.39, p<0.001, Cohen's d=2.02]. In addition, students using cochlear implants received scores lower than normal-hearing students in both areas (Figure 1).
Table 2 shows the correlation of total reading scores and total writing scores of students with cochlear implants. A positive correlation (r=0.86) can be found between the total writing and reading scores of students with cochlear implants (Figure 2). On the other hand, there was no significant relationship between the reading and writing scores of the normal-hearing group. Both sets of scores are independent of each other.
Table 3 shows the effects of age of cochlear implantation and the durationof cochlear implant use on the total reading and writing skills of students (Figure 3). No significant relationship was found between the variables tested.
Table 4 shows the division of students implanted according to implantation surgery time: 36 months and before, and after 36 months. On the other hand, the relationships between the age of implantation and the duration of cochlear implant use and the variables of total reading score and total writing score were examined. No significant relationship was found between the variables being tested and the age of implantation and duration of implant use (Figure 4).
A statistically significant difference was found between students with implants and their normal-hearing peers in terms of both reading and writing skills. This difference indicated that students who use cochlear implants scored significantly lower in reading and writing skill levels than their normal-hearing peers. When the standard deviations of participants' scores were examined, we found that the standard deviations of students using implants were high. According to this finding, which showed high intra-group variance, there were low and medium as well as high reading and writing performances among students using cochlear implants. The intra-group variance low the normal-hearing group, and the reading and writing skill levels of normal-hearing students were close to each other. Similarly, in another study, when the literacy skills of hearing-impaired children were significantly behind the level of their normal-hearing peer, and only 30% can functionally develop literacy skills [2, 12-15]. Karasu et al.  evaluated the reading skills of cochlear-implanted and normal-hearing students. Similar to the findings of the present study, they found that students using cochlear implants can develop certain reading skills, but that such skills are far behind than those of their normal-hearing peers.
For the age of implantation, there was no statistically significant effect on the means of reading and writing scores being tested for students implanted. The age of implantation did not have a statistically significant effect on the total reading and writing scores of students implanted, owing to the heterogeneous distribution and the high variance of the group. If the intra-group variance was lower and the number of participants was higher, the age of implantation would significantly affect the total reading and writing scores of students with implants. When participants were divided into two groups, those who had an implant at 36 months and before (as an early group) and those who had an implant at 36 months (as the late group), we found that the implantation age did not have a significant effect on the variables. According to this, no statistically significant difference was found between the reading and writing scores of students with implants between 36 months and before, and at 36 months after implantation surgery. Furthermore, the standard deviation values obtained in the reading and writing scores indicated that the intra-group variance was high, suggesting a heterogeneous group distribution. Students in the implanted group (36 months and before/at 36 months after the surgery) both had low and high reading and writing scores. The time of implant use had no statistically significant effect on the variables being tested (reading and writing scores). According to the findings, if a sufficient number of participants were included, the time of implant usage would suggest a significant effect on the reading skill. However, the opposite was found in terms of the written expression skills of students with implants. The intra-group variance of cochlear implant users for writing scores was not high, suggesting that implant users provided similar written narrative points. This finding supports the fact that the duration of implant use is not a significant influence on the writing score.
Geers  compared the reading performance of children with implants and their normal-hearing peers in a study, whose findings are similar to those of the present study. She found no significant relationship between the duration of cochlear implant use and reading ability in the implanted group. Similarly, Willsredt-Svenson et al.  did not find a direct relationship between reading skills and implant age and duration of implant use. In contrast to the findings of the present study, Trawler [12, 18] reported a statistically significant relationship between the duration of implant use and literacy skills of hearing-impaired children in his normative data.
One of the important variables affecting the reading and writing performances of children is the diagnosis time of hearing loss . In the present study, diagnosis time was at approximately 1 year of age (although these children were already using hearing aids during 18-24 months). According to the literature, the fastest period of language development for babies is during 0-24 months. Speech and language skills of hearing-impaired children who are not adequately exposed to sound stimuli during language development are adversely affected [1,2 0, 21]. For children with hearing loss, beginning to use hearing aid at 1 year of age may be too late because the loss of hearing time also affects the development of reading and writing skills . Similar to the literature, the fact that participants in the present study started to use hearing aids at a later time, this delay may have had a negative effect on their reading and writing development. All participants except for one used hearing aids before implantation. Only eight of the participants used hearing aids before 18 months of age, the rest were prescribed hearing aids after 18 months of age.
According to the literature, children who received cochlear implants before the age of 2 are at the same speech and language development level as their hearing peers when they reach the age of 5. Similarly, the auditory discrimination abilities of children implanted before the age of 2 are closer to those of their normal-hearing peers compared with children who received their implants after the age of 2 [23-26].
In the present study, owing to insufficient number of participants, early and late implants were divided into two groups according to the time of surgery (before 36 months and after 36 months).
When looking at the age of implantation, only four students had implant surgery before the age of 2 years, the rest had their implants after the age of 2 years. The reason for not finding any significant effect of implantation on reading and writing skills could be the later age limit set to separate the early and late groups.
Many factors can influence the reading ability of hearing-impaired children. Geers  reported that such factors include onset of hearing loss, diagnosis time, intelligence level, and biological age of babies. The implant fitting software, the number of active electrodes, and the dynamic range are also considered as the implant-dependent properties that can affect the subsequent reading ability of children.
While reading and writing scores of patients with implants were related to each other, there was no relation between the reading and writing scores of normal-hearing students. In this context, the reading and writing scores of normal-hearing students were obtained independently of each other. In a normative data study of children with hearing impairment, Traxler  noted that hearing-impaired children do not develop age appropriate reading and writing skills. As a result, a hearing-impaired child who has not developed reading skills cannot improve his writing skills. Supporting our findings, Geers and Hayes  argued that hearing-impaired children are less exposed to environmental stimuli than their normal peers, and that this reflects negatively on their speech and language development as well as on their subsequent ability to read and write.
The reading skill development of hearing-impaired individuals, whose language development is slow due to hearing loss, can also be adversely affected by this process . Similarly, Antia et al.  argued that children with hearing impairment, whose language development is slow, find it very difficult to communicate through writing. Hence, according to these findings, while speech and language development is negatively affected by hearing loss, the slow language development process in different studies negatively affects one's reading and writing skills. As a result, the development of reading and writing skills of individuals suffering from slow language development can be negatively affected.
In conclusion, children who use cochlear implants develop lower levels of reading and writing skills than their normal-hearing peers, even if they go to normal schools together. Early implantation has positive effects on speech and language skills development, but differences in the reading and writing skills of these children compared with those of their normal-hearing peers are observed in higher grades (6th, 7th, and 8th grades). The age of implantation and the duration of implant use are not the only factors affecting the language development and academic performance in children using implants. The use of these assessment scales in cochlear implant recipients and hearing aids does allow children to be compared with their normal-hearing peers for abilities other than speech and language.
Ethics Committee Approval: Ethics committee approval was received for this study from the Ethics Committee from Marmara University (19.01.2016-14).
Informed Consent: Written informed consent was obtained from the patient's parents who participated in this study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept - H.C., A.C.; Design - H.C.; Supervision - A.C.; Resource - H.C.; Materials - H.C.; Data Collection and/or Processing - H.C.; Analysis and/or Interpretation - H.C., A.C.; Literature Search - H.C.; Writing - H.C., A.C.; Critical Reviews - A.C.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no financial support.
[1.] Yoshinaga-Itano C, Sedey A, Coulter DK, Mehl AL. Language of early- and later-identified children with hearing loss. Pediatrics 1998; 102: 1161-71. [CrossRef]
[2.] Tiryaki EN. Multi variable evaulation of writing skills deaf students at secondary school. Mustafa Kemal Universitesi Sosyal Bilimler Enstitusu Dergisi 2014; 11: 247-58.
[3.] Girgin U, Karasu HP. Assessment of written expression skills in hearing impaired students trained with the auditory/oral approach. Hacettepe Universitesi EGitim Fakultesi Dergisi 2007; 33: 146-56.
[4.] Geers AE, Nicholas JG, Moog JS. Estimating the influence of cochlear implantation on language development in children. Audiol Med 2007; 5: 262-73. [CrossRef]
[5.] Marschark M, Rhoten C, Fabich M. Effects of cochlear implants on children's reading and academic achievement. J Deaf Stud Deaf Educ 2007; 12: 269-82. [CrossRef]
[6.] Pisoni DB, Cleary M, Geers AE, Tobey EA. Individual differences ineffectiveness of cochlear implants in children who are prelingually deaf: New process measures of performance. Volta Rev 1999; 101: 111-64.
[7.] Niparko JK, Tobey EA, Thal DJ, Eisenberg LS, Wang NY, Quittner AL, et al. Spoken language development in children following cochlear implantation. JAMA 2010; 303: 1498-506. [CrossRef]
[8.] Wu CM, Ko HC, Chen YA, Tsou YT, Chao WC. Written language ability in mandarin-speaking children with cochlear implants. BioMed Res Int 2015. Article ID 282164.
[9.] Wu M, Lee LA, Chao WC, Tsou YT, Chen YA. Paragraph-reading comprehension ability in mandarin-speaking children with cochlear implants. Laryngoscope 2015; 125: 1449-55. [CrossRef]
[10.] Karasu HP. Assessment of writing skills of hearing impaired students who attend mainstream classes. Dissertation 2004; Anadolu University, Eskisehir.
[11.] Karasu P, Girgin U, Uzuner Y. Evaluation of Cloze Procedure Skills of Hearing-Impaired and Normally-Hearing Students. Anadolu Journal of Educational Sciences International 2013; 12: 701-12.
[12.] Traxler CB. The Stanford Achievement Test, 9th Edition: National Norming and Performance Standards for Deaf and Hard-of-Hearing Students. J Deaf Stud Deaf Educ 2000; 5: 337-48. [CrossRef]
[13.] Kyle FE, Harris M. Concurrent correlates and predictors of reading and spelling achievement in deaf and hearing school children. J Deaf Stud Deaf Educ 2006; 11: 273-88. [CrossRef]
[14.] Harris M. The impact of new technologies on the literacy attainment of children with severe-profound hearing loss. Top Lang Disord 2015; 35: 120-32. [CrossRef]
[15.] Dammeyer J. Literacy skills among deaf and hard of hearing students and students with cochlear implants in bilingual/bicultural education. Deafness Education International 2014; 16: 108-19. [CrossRef]
[16.] Geers AE. Speech, language, and reading skills after early cochlear implantation. Arch Otolaryngol Head Neck Surg 2004; 130: 634-8. [CrossRef]
[17.] Willstedt-Svenson U, Sahlen B, Maki-Torkko E, Lyxell B,Ibertson T. Prelingually deaf children children with cochlear implant-Phonological skills, working memory capacity and reading related development. 10th International Conference on Cochlear Implants in Children: Dallas TX; 2005.
[18.] Spencer LJ, Barker BA, Tomblin JB. Exploring the language and literacy outcomes of pediatric cochlear implant users. Ear Hear 2003; 24: 236-47. [CrossRef]
[19.] Geers AE. Predictors of reading skill development in children with early cochlear implantation. Ear Hear 2003; 24: 59S-68S. [CrossRef]
[20.] Apuzzo ML, Yoshinaga-Itano C. Early identification of infants with significant hearing loss and the Minnesota Child Development Inventory. Semin Hear 1995; 16: 124-35. [CrossRef]
[21.] Yoshinaga-Itano C, Snyder L. The relationship of language and symbolic play in deaf and hard-of-hearing children. Volta Review 1999; 100: 135-64.
[22.] Geers A. Factors affecting the development of speech, language, and literacy in children with early cochlear implantation. Lang Speech Hear Serv Sch 2002; 33: 172-83. [CrossRef]
[23.] Kirk KL, Miyamoto RT, Ying EA, Perdew AE, Zuganelis H. Cochlear implantation in young children: Effect of age at implantation and communication mode. Volta Rev 2000; 102: 127-44.
[24.] Govaerts PJ, De Beukelaer C, Daemers K, De Ceulaer G, Yperman M, Somers T, et al. Outcome of cochlear implantation at different ages from 0 to 6 years. Otol Neurotol 2002; 23: 885-90. [CrossRef]
[25.] Estabrooks W, Maclver-Lux K,Rhoades EA, editors. Auditory-Verbal therapy: theory and practice. Washington DC: AG Bell; 2006.
[26.] Wie OB, Falkenburg ES, Tvete O, Tomblin B. Children with a cochlear implant: Characteristics and determinants of speech recognition, speech recognition growth rate and speech production. Int J Audiol 2007; 46: 232-43. [CrossRef]
[27.] Geers AE, Hayes H. Reading, writing, and phonological processing skills of adolescents with 10 or more years of cochlear implant experience. Ear Hear 2011; 32: 49S-59S. [CrossRef]
[28.] King CM, Quigley SP. Reading and deafness. San Diego, Calif.: College-Hill Press; 1985.
[29.] Antia SD, Reed S, Kreimeyer KH. Written language of deaf and hard of hearing students in public schools. J Deaf Stud Deaf Educ 2005; 10: 244-55. [CrossRef]
Hulya Cizmeci [iD] Ayca Ciprut [iD]
Department of Audiology, Marmara University School of Medicine, Istanbul, Turkey
Cite this article as: Cizmeci H, Ciprut A. Evaluation of the Reading and Writing Skills of Children with Cochlear Implants. J Int Adv Otol 2018; 14(3): 359-64.
This study was presented at the 12th International Congress of Ear, Nose, Throat and Head and Neck Surgery, 9 April 2016, Ankara, Turkey.
Corresponding Address: Hulya Cizmeci E-mail: firstname.lastname@example.org
Submitted: 15.08.2017 * Revision Received: 05.12.2017 * Accepted: 25.12.2017 * Available Online Date: 02.08.2018
Table 1. Total reading and writing scores of students with normal-hearing and those with implants Students with cochlear implants (n = 20) Variables Ave.[+ or -]SD Min. Max. Total reading scores 46.40[+ or -]29.76 0.00 92.00 Total writing scores 49.05[+ or -]22.49 0.00 86.00 Normal-hearing students (n = 20) Variables Ave.[+ or -]SD Min. Max. t Cohen's d Total reading scores 83.85[+ or -]5.61 71.00 94.00 -5.23 (*) 1.75 Total writing scores 82.60[+ or -]6.68 69.00 95.00 -6.39 (*) 2.02 Ave.: average; SD: standard deviation; Min.: minimum; Max.: maximum (*) p<0.001. Table 1 shows the total reading and writing scores of students with normal-hearing and those with implants. A significant relationship was observed between implanted and normal-hearing students in terms of their total reading scores [t (20.35) = -5.23, p<0.001, Cohen's d=1.75] and total writing scores [t (22.33) = -6.39, p<0.001, Cohen's d=2.02]. In addition, students using cochlear implants received scores lower than those with normal-hearing in both areas. Table 2. Correlations of total reading and total writing scores of students with cochlear implant Age of implantation Duration of CI use 1. Age of implantation 1 2. Duration of CI use -0.61 1 3. Total reading score -0.16 -0.15 4. Total writing score -0.20 0.03 Total reading score Total writing score 1. Age of implantation 2. Duration of CI use 3. Total reading score 1 4. Total writing score 0.86 (**) 1 CI: Cochlear Implantation (**) p =.0000001 Table 2 shows the correlations of total reading score and total writing scores of students with cochlear implants. A positive correlation (r=0.86) can be found between the total writing and reading scores students with cochlear implants Table 3. The effects of cochlear implantation age and the total time of cochlear implant use on writing and reading scores Total reading scores [beta] t p sr Age of CI -0.41 -1.43 0.172 -0.323 Total time of CI use -0.40 -1.39 0.182 -0.315 R2=0.13, F(2,17) = 1.23, p = 0.317 Total writing scores [beta] t p sr Age of CI -0.30 -1.01 0.327 -0.238 Total time of CI use -0.16 -0.53 0.603 -0.125 R2 = 0.06, F(2,17)=0.52, p=0.607 sr: semipartial coefficient; [beta]: standardized regression coefficient; CI: cochlear implantation Table 3 shows the effects of cochlear implantation age and the total time of cochlear implant use on writing and reading scores. No significant relationship was found between the variables tested. On the other hand, the relationships between the age of implantation and the total time of cochlear implant use and the variables of total reading score and total writing score were examined. No significant relationship was found between the variables being tested and the age of implantation and duration of implant use. Table 4. Effects of implantation surgery time (36 months and before and after 36 months) on the reading and writing scores of students with implants 36 months and before After 36 months Variables Ave.[+ or -]SD Ave.[+ or -]SD t Total reading scores 54.25[+ or -]26.29 34.62[+ or -]32.49 1.49 Total writing scores 53.58[+ or -]21.92 42.25[+ or -]23.02 1.11 SD: standard deviation; Ave.: average score Table 4 shows the division of students with implants according to implantation surgery time: 36 months and before and after 36 months. No significant relationship was found between the variables tested
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Original Article|
|Author:||Cizmeci, Hulya; Ciprut, Ayca|
|Publication:||The Journal of the International Advanced Otology|
|Date:||Dec 1, 2018|
|Previous Article:||Comparison of a Traditional and Novel Evoked Compound Action Potentials Recording Approach and Evoked Auditory Brainstem Responses in Pediatric...|
|Next Article:||Impact of Routine Plain X-ray on Postoperative Management in Cochlear Implantation.|