The impact of language
underperformance on social and
communication functioning in
children with cochlear implants
Jareen Meinzen-Derr, Susan Wiley,
Sandra Grether, Holly Barnard, Julie Hibner,
Daniel Choo, Laura Smith
Background
• Social and communication functional skills are
essential for independence
– Skills require language
• Research in deaf/hard of hearing limited
– “Functional performance” commonly used to describe
functional hearing
• Literature supports language acquisition, but
often omits practical benefits of language
Objective
• To assess how language levels impact
social and communication functioning in
young children with cochlear implants
• Does having a language level that is lower
than your cognitive abilities impact your
daily functional skills?
Eligibility
3-6 Years
Bilateral
hearing loss
prelingual
NVIQ
40-79
NVIQ
>80
Nonverbal IQ
>40
Balanced regarding degree of hearing loss and age
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
Outcome Measure
Pediatric Evaluation of Disability Inventory
• Comprehensive standardized measure of
essential daily functional activities
– 197 discrete functional skill items
– Self-care, mobility, social function
– Standard (mean 50+10) and Scaled Scores
• Useful in treatment planning and identifying
specific areas where assistance is needed
Social Function Domain
• Comprehension Word
Meanings
• Comprehension of
Sentence Complexity
• Functional Use of
Communication
• Complexity of
Expressive
Communication
• Problem-resolution
• Social Interactive Play
(adults)
• Peer Interaction (child
of similar age)
• Play with Objects
• Self-Information
• Time Orientation
• Household Chores
• Self-Protection
• Community Function
Outcome Measure
Vineland Adaptive Behavior Scales
• Reflects the individual’s personal and social
skills as he/she interacts with environment
– 383 items
– Communication, Daily living skills, socialization,
motor skills
– Standard scores (mean 100+15)
• Can measure adaptive behavior in different
subgroups
Defined Language “Gap”
Language abilities relative to cognitive abilities
Receptive Language standard score
LANGUAGE:COGNITIVE RATIO
Nonverbal IQ standard score
LANGUAGE =
80
IQ = 100
80/100 or (0.80*100)=80
>50% have a language to
cognitive ratio <80
n=41
Characteristics
Mean Age of study (months)
58.5
SD 13
Male
20
49%
Etiology of HL unknown
18
44%
Born premature
3
7.3%
31.1
15.7
24
58.5%
HS/GED
Some college
College
Post graduate
7
15
8
11
17%
36.5%
19.5%
27%
Private
Public
Combo
16
17
8
39%
41.5%
19.5%
20
50%
Duration of Implant in months
Bilateral CI
Maternal education
Insurance
Income <$50,000
Functional Skill Outcomes
Pediatric Evaluation of
Disability Inventory
(mean of 100)
(t-score of 50)
65
110
105
100
95
90
85
80
75
70
65
60
55
50
60
55
PEDI Standard Score
VABS Standard Scores
Vineland Adaptive Behavior
Scales
50
45
40
35
30
25
20
15
10
5
0
Commun. Social
Daily
Motor Adaptive
Self Care
Mobility
Social Function
Vineland Adaptive
Behavior Scales
Pediatric Evaluation of
Disability Inventory
(mean of 100)
(t-score of 50)
110
65
100
55
90
45
80
70
60
50
35
CI
HA
25
15
5
-5
CI
HA
Communication and Social Function
among Children with CI
VABS COMMUN.
β
P-VALUE
0.25
0.34
-0.42
2.31
0.034
0.003
0.009
0.002
PEDI SOCIAL
β
P-VALUE
NONVERBAL IQ
0.48
0.37
-4.16
-7.7
<.0001
0.002
0.046
0.058
NONVERBAL IQ
RECEPTIVE: IQ
WORKING MEMORY
SES SCORE
RECEPTIVE: IQ
PREMATURE
UNKNOWN ETIOLOGY
PARTIAL R2 TOTAL R2
0.315
0.266
0.066
0.106
0.315
0.581
0.647
0.753
PARTIAL R2 TOTAL R2
0.292
0.121
0.056
0.052
0.292
0.413
0.469
0.521
NS: receiving therapy, aided SRT/SAT, duration with implant, age of implant, mom education
PEDI Social Function Score
Adjusted mean PEDI social function
scores (adjusted to scale of 100)
115
110
105
100
95
90
85
80
75
70
65
60
55
50
45
40
35
COMMENSURATE LANGUAGE
LOW LANGUAGE
p=0.007
TOTAL
IQ >95
IQ 80-95
Range of Nonverbal IQ
IQ <80
Adjusted Mean Vineland Communication
Scores
Communication Function Score
115
COMMENSURATE LANGUAGE
110
LOW LANGUAGE
105
100
95
90
85
80
75
70
p=0.008
65
60
55
50
TOTAL
IQ >95
IQ 80-95
Range of Nonverbal IQ
IQ <80
In Summary
• Low language performance has functional
impact on communication and social skills
– Impact among a broad range of IQ
– Language does not have to be “sub-normal”
• Strive to meet a child’s potential, but be
cognizant of the role sub-optimal language
levels
• Consider interventions specific for improving
pragmatic language and social skills
What does this mean?
• Language is directly related to social and
communication functioning
– Language gap significantly impacts this
functioning negatively
• The gap does not mean below average
– It is easy to become “complacent” regarding
“normal” language scores
• Current study includes 0-3y population to
determine a developmental profile of
children who may need early support
0-3 year old group:
Language Gap is not widening with age
Already seeing decline in social
functioning with increasing age
Early relationship between ratio
and communication functioning
Early relationship between ratio
and social functioning
Future Directions
• Pilot augmentative technology intervention
trial
• Children enrolled in the study with a language
gap (irrespective of technology use) are
eligible for an assistive technology
intervention
• Receive i-Pad with Word Power software
(locked down for other app use during
intervention period)
Future Directions
• Participation in 6 weeks of weekly aug comm
therapy followed by 6 weeks at home and
final 6 weeks of therapy
Evaluation,
language
sample
6 weeks
intervention
6 weeks
home
practice
6 weeks
intervention
Evaluation,
language
sample
• Useage of i-pad monitored
• Language changes pre- to post- intervention
measured
– Syntax, grammar, MLU
Early Qualitative Findings
• 2 children enrolled:
– 1 with average non-verbal IQ
– 1 with below average non-verbal IQ
• Quick learning noted by both
• Increased speech production within one
session of therapy by child with non-verbal IQ
• Increased sentence length with better
grammar in child with average IQ
Thank You
Special thanks to
Sandi Bechtol, RN
Meredith Tabangin, MPH
CCHMC Audiology
Boys Town National Research
Hospital (Mary Pat Moeller &
Barbara Peterson)
Participating Families
HRSA MCHB R40MC21513, March of Dimes #12-FY14-178
Extra slides
Communication function for cohort
Communication Function Score
115
COMMENSURATE LANGUAGE
110
LOW LANGUAGE
105
100
95
90
85
80
75
70
65
60
55
50
TOTAL
IQ >95
IQ 80-95
Range of Nonverbal IQ
IQ <80
PEDI Social Function Score
Social Function for cohort
115
110
105
100
95
90
85
80
75
70
65
60
55
50
45
40
35
COMMENSURATE LANGUAGE
LOW LANGUAGE
TOTAL
IQ >95
IQ 80-95
Range of Nonverbal IQ
IQ <80