Factors associated with “language gaps” among children with cochlear

implants

Susan Wiley, J Meinzen-Derr, S Grether, H Barnard, D Choo, J Hibner, L Smith

Background

• Language skills are highly correlated with academic, occupational, and social success

• Language “gaps” can impart challenges in academics, social-emotional functioning vocational opportunities, and subsequent earning potential

Background

• Relatively large numbers of children who are DHH struggle with significantly lower language levels disproportionate to their scores on nonverbal cognitive assessments

• These lags in early language can have a larger impact through the school years as the language demands increase, irrespective of hearing loss severity

Background

• Despite early identification and intervention as well as the positive impact of technology, language levels continue to hover in average to low average range for many– Expect 50% have scores >100 and 35% scores

>115

• Language scores are often used as a “target”– Do not account for an individual’s capability

Objectives of Larger Study• Determine the extent to which nonverbal cognitive

IQ (NVIQ) explains the divergence between language level and cognitive level

• Determine specific audiologic features that impact the divergence between language and cognitive level among children with cognitive disabilities

• Characterize the language-based interventions for children with hearing loss and cognitive disabilities.

Objective of Presented Work

• Determine factors associated with an underperformance of language among children with cochlear implants

Eligibility of overall study

• Enrolled 93 children, congenital permanent bilateral hearing loss

• Ages 3 – 6 years• Nonverbal IQ >40• Enrolled hearing children with below average

Nonverbal IQ• Exclusions: Autism spectrum disorders, unable

to complete standardized assessments• 41 children with cochlear implants

Eligibility

Balanced regarding degree of hearing loss and age

3-6 Years

Bilateral hearing loss

prelingual

Nonverbal IQ >40

NVIQ40-79

NVIQ>80

Assessment Tools• Language Assessment:

– Preschool Language Scales -5

• Neurocognitive Assessment: – Leiter International Performance Scale-R, Behavioral

Rating Inventory of Executive Function

• Functional Assessment– Pediatric Evaluation of Disability Inventory– Vineland Adaptive Behavior Scales

• Detailed family questionnaire and medical chart review

Language Performance

LANGUAGE:COGNITIVE RATIO

IQ = 100LANGUAGE = 80

80/100 or 0.80

Defined as language abilities relative to cognitive abilities

Receptive Language standard scoreNonverbal IQ standard score

Statistical Analysis• Bivariate analysis occurred between each outcome

variable (absolute language scores and the ratio of language level to NVIQ)

• The relationship between continuous values of NVIQ and other factors was investigated using Pearson correlation with continuous variables and analysis of variance (ANOVA) or t-test for categorical variables

• We constructed multivariable general linear models to assess the amount of variability (using the coefficient of determination or R2) in outcomes explained by NVIQ

Characteristics CIn=41

HAn=49

Mean Age of study (mos) 58.5 (13) 56.7 (14.6)

Etiology of HL unknown 44% 49%

Duration of Implant 31.1 (15.7)

Bilateral CI 58.5%

Contralateral HA (bimodal) 15%

Maternal education college or post graduate 46.3% 61.2%

Public Insurance 41.5% 32.7%

Income <$50,000 51.2% 40.8%

Have siblings 75% 81.3%

Etiology of hearing loss: comparison CI and HA

UNKNOWN INNER EAR SYNDROME INFECTIOUS GENETIC PREMATURITY OTHER0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%CI HA

Mean Cognitive and Language Scores Entire Group

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110

COCHLEAR IMPLANT HEARING AID

Blue: non-verbal cognitive IQPink: receptive language scoreGray: expressive language score

Nonverbal IQ Receptive Expressive

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Mean Cognitive and Language Scores (CI Group Only)

p<0.0001

Language and cognitive characteristics among entire cohort

Characteristic Normal CognitionNVIQ>100

Low Avg Cognition

NVIQ 80-99

Low cognitionNVIQ<80

Non-verbal IQ (SD) 111 (9) 90 (7) 67 (10)

Working Memory T Score 52 (10) 60 (12) 59 (9)

Working Memory score >65 13% 37% 17%

Receptive Language Score 94 (13) 77 (17) 66 (12)

% receptive score <80 12.5% 63% 85%

Ratio of Language:Cognition 85 (12) 85 (20) 92.1 (31)

% with language gap 35% 43% 25%

Language and cognitive characteristics among children with CI

Characteristic Normal CognitionNVIQ>100

Low Avg Cognition

NVIQ 80-100

Low cognitionNVIQ<80

Non-verbal IQ (SD) 115 (9) 91.1(7) 66 (11)

Working Memory T Score 49 (10) 59 (13) 57 (6)

Working Memory score >65 10% 33% 0

Receptive Language Score 86 (16) 73 (16) 58 (9)

% receptive score <80 27% 71% 100%

Ratio of Language:Cognition 75 (12) 80 (18) 75 (24)

% with language gap 73% 57% 44%

Factors associated with better language performance (higher ratios) in entire group

PREDICTORS β p-value

DECREASING NONVERBAL IQ* -0.61 <.0001

BETTER WORKING MEMORY -0.21 0.12HEARING AIDS VS. UNILATERAL CI 23.1 <.0001BILATERAL CI VS. UNILATERAL CI 12.4 0.015INCREASING SES SCORE 2.38 <.0001

BETTER AIDED SRT/SAT -0.42 0.009

R2 0.57

NS: siblings, weekly hours of therapy, duration with implant/hearing age, age of implant, using any sign language, age of identification, age of child

Among children with cochlear implants, factors associated with better language performance

PREDICTORS β p-value

DECREASING NONVERBAL IQ* -0.52 0.002

BETTER WORKING MEMORY -0.57 0.010BILATERAL CI 23.6 0.0003BIMODAL – USE HA 15.5 0.057

INCREASING SES SCORE 2.38 0.011

R2 0.506NS: siblings, receiving therapy, duration with implant, age of implant, using any sign language

Nonverbal IQ60 70 80 90 100 110

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115

Performance as a function of NVIQ

Bilateral CI

Nonverbal IQ60 70 80 90 100 110

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Performance as a function of NVIQ

Unilateral CI

Bilateral CI

Nonverbal IQ categories

IQ>100 IQ 80-100 IQ <80

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130HA BILATERAL CI UNILATERAL CI

Adjusted mean language ratios by NVIQ categories

Adjusted for working memory and SES

Conclusions

• Although many children are achieving average language abilities, many are still underperforming according to their cognitive potential– Downstream effect of language gaps

• There seemed to be a modest benefit to bilateral cochlear implantation on language outcomes (however more research warranted)

Thank YouJareen Meinzen-Derr, PhD (DBE)

Daniel Choo, MD (ENT)

Sandra Grether, PhD (SLP)

Holly Barnard, PhD (Neuropsych)

Julie Hibner, MS (SLP)

Michael Scott, AuD (Audiology)

Laura Smith, MPH (CRC)

Meredith Tabangin, MPH

Boys Town National Research Hospital (Mary Pat Moeller & Barbara Peterson)

HRSA MCHB R40MC21513, March of Dimes #12-FY14-178