Communication Development in
Children with Cochlear Implants
Antonia Brancia Maxon, Ph.D.
Diane Brackett, Ph.D.
Jennifer Cox, M.A.
Alicia Ayles, M.A.
Megan Kessler, M.A.
New England Center for Hearing
Rehabilitation
Hampton, CT
EXPECTATION
• Children who grow up using cochlear
implants have the potential to develop
superior spoken language skills.
• Achievement of that potential is
dependent on:
– quality of the auditory information (MAP)
– dependence on auditory information
– input from parents/therapists/children
– high expectations
How Cochlear Implants Work
• Cochlear implants are designed to bypass
damaged hair cells and stimulate the
auditory nerve directly through the
application of electrical current
• The cochlear implant replaces damaged
hair cells in the cochlea and does their job
for them
UNHS lowers age of intervention
• Infants with hearing loss should be fit with
hearing aids by four months old at the latest.
• Infants with hearing loss should be enrolled in
early intervention by four months old at the
latest.
• Benefit from traditional amplification can be
determined by 10 months old at the latest.
UNHS affects the age of cochlear
implant candidacy identification
• 12 months is recommended lowest age.
– Surgeons are implanting even younger infants.
• Infants/toddlers who cannot benefit from
traditional amplification
– degree of loss prevents access to normal
conversational level speech with amplification
– configuration of loss prevents access to critical
speech sounds with amplification
Benefits of Early Cochlear Implantation
• Minimizes the effects of auditory
deprivation
• Electrical stimulation provides necessary
information to auditory system at critical
period for speech and language
acquisition.
• Provides child with a good chance to
develop normal speech and language
Early Intervention and Language
Acquisition
• Avoid or decrease potential auditory
deprivation that may result in
– vocabulary delay (2-3 years at school age)
– verbal concepts acquired at slower rate
– more concrete language, i.e., difficulty with
• multiple meanings
• multiple words for same concept
• “richness” of vocabulary
Early Intervention and Language
Acquisition
• Reduce negative impact on initial
vocabulary learning
– incidental learning
• Reduce negative impact on social
interaction
– idiomatic expressions
– slang
Language from Identification to age 3
– Discriminates people’s voices
– Discriminates songs
– Soothed by the presence of
familiar voice
– Recognizes many familiar
words and phrases
– Auditory memory of 2 items in a
phrase (Put Elmo on the table.)
– Can produce most consonants
and all vowels
Language from Identification to age 3
• Understands common verbs
• Understands “What” and “Where”
questions
• Produces sentences with a
subject and verb
• Uses grammatical forms including
plurals (doggies) and present
progressive (Doggie is walking)
• Likes to sing
• Can (and will) repeat back
“naughty” words
• Speech is intelligible to familiar
adults
Age 3 to 5 (home language)
• Understands and can attend to
longer stories at night
• Beginning to use conjunctions,
such as “and”.
• Understands ‘knock-knock’
jokes
• Able to tell stories and ‘tattle’
on siblings, often recounting
great detail.
• Able to produce more
consonants and some
‘blended’ sounds such as /br/
Age 3 to 5 (preschool language)
• Can attend to short stories during
circle time.
• Can follow teacher’s instructions
• Can talk with other students,
knows when to ask for clarification
and when to clarify not understood
• Can verbally engage in play
• Uses pronouns he/she, him/her
• Answers most “WH” questions
• Asks “Why?”
• Able to follow three step
commands
Age 5 to 8 (home language)
• Learning how to negotiate verbally
(Those cookies sure smell good.)
• Adapts to the listener, (changing
for stranger, infant vs. adult)
• Produces definitions of words
when asked
• Uses most irregular past tense
verbs, such as drank, hid, blew.
Age 5 to 8 (school language)
• Is expected to understand
instructional language in the
classroom, for example, “Put
your name at the top of the
page in pencil.”
• Vocabulary learning becomes
more curriculum-based.
• Understands non-literal
requests
• Produces anecdotal narratives
• Uses more conjunctions, such
as “if”, “but”, “when”
Ages 8 to 11 (social language)
• Able to understand the rules of
the game (Infield fly rule)
• Able to understand the figurative
language of sports (Choke up on
the bat)
• Able to advocate for one’s self
when rules or instructions are not
heard or understood
Ages 8-11 (school language)
• Use of mass nouns (team,
troop, class, chorus)
• Use of complex verb forms
(He could have fallen off
the...)
• Use of clause structures (If I
were walking in the rain I
would need an umbrella.)
• Able to repair semantic
absurdities (The mother read
a lullaby to the baby.)
Ages 8 to 11 (school language)
• Expected to adjust to the
different rules and routines of
many teachers
• Understands passive voice (The
fish was caught by the boy.)
• Able to make inferences
• Able to use language to compare
and contrast (Why or How
things are the same or different)
Ages 12-17 (social)
• Group conversational skills
• 1:1 relationships (intimate
language)
• Confrontational language
• Flirting language
• Understanding dating
language
• Sarcasm/nuance
• Clichés
• Slang
Ages 12-17 (school)
• Interpretation and analysis of
information
• Hypothesis testing
• High level math language
• Embedding
• Test taking language and
procedures
• Research and report writing
• Driver’s education
(language)
NECHEAR Children with Cochlear
Implants
• Demographic
– Number of children = 20
• Bilateral implants = 7
• Additional developmental = 2
– Age at CI = 13 – 108 months
• Mean Age = 35.75 months
– Therapy = Aural/Oral, Auditory Verbal
– School placement = Regular Education
– Communication mode = Auditory Oral
Six Years Post-Implant
• Test data are presented as mean standard
scores (100 = 50th percentile)
• All data reflect number of years postcochlear implant
– These data are limited to six years after
implantation
– All data were obtained through routine annual
communication evaluations
Listening Skills
• Speech perception assessment
• Boothroyd’s Isophonemic nonsense
syllables
– CVCs
– Each list 10 items
– Auditory only presentation
– Talk-back response
Listening Skills
Isophonemic Nonsense Syllables
100
Percent Correct
95
90
Vowels
Consonants
Phonemes
85
80
75
70
1
2
3
4
5
6 Years Post Implant
Speech Production
• Single word and connected speech
– > 5 years: 100% single word, 95% connected
– < 5 years: single word - age appropriate, e.g.,
w/r, w/l, interdental lisp, all produced fricatives
– 1 child with oromotor problems – 90% single
word, 70% connected speech
Vocabulary Test
• Peabody Picture Vocabulary (PPVT)
– Receptive single word: nouns, verbs,
adjectives, adverbs
– Picture point 1 out of 4 items
• Expressive Vocabulary Test (EVT)
– Expressive single word: nouns, verbs,
adjectives, adverbs
– Label pictures – provide synonym for picture
and given label
Semantics
Receptive and Expressive Vocabulary
150
Standard Score
140
130
120
110
100
90
80
PPVT
EVT
70
60
50
1
2
3
4
Years Post Implant
5
6
Syntax and Figurative Language Tests
• CASL (spoken language): multiple
subtests
– Syntax Construction subtest
• e.g., “Here is a bird.” “Here _____ (two birds)
– Figurative Language subtest
• e.g.,” Tom stopped what he was doing when he
saw the red light flash on his mother’s face.”
Standard Score
Syntax – Expressive
150
140
130
120
110
100
90
80
70
60
50
Syntax
1
2
3
4
Years Post Implant
5
6
Standard Score
Figurative Language – Receptive
150
140
130
120
110
100
90
80
70
60
50
Figurative
1
2
3
4
Years Post Implant
5
6
Assessing Auditory Function
• Child needs to receive speech at an
appropriate useable level with
amplification
– detection is not enough
– have to look across frequencies for access to
all speech sounds
– speech needs to be received at a level that
allows for learning language
Assessing Auditory Function
• Child must have good access to
– speech at different distances from sound source
– speech of others
– own speech
• Child should be able to alert
– to a variety of speech sounds
– to a variety of non-speech sounds
– at a variety of distances from the sound source
Mapping Audiologist Needs
Information: Adjustment Indicators
• CHANGES in speech production and/or
perception
– child can no longer hear or say a sound
previously heard/said
• says “ee” for “see”
– child is substituting one speech sound for
another
• says “bad” for “dad”
Mapping Audiologist Needs
Information: Adjustment Indicators
• Changes in speech pattern
– sounds “mushy”
– drops final consonants
– confuses: /p,t,k/, /n,m/, close vowels (/u, o/)
• Increase in distortions
– /t/ becomes /s/, /st/ for /s/
• Vowels flatten
– /ee/ becomes /eh/
Mapping Audiologist Needs
Information: Adjustment Indicators
• Reduction of syllables in multisyllabic
words
• Increase in “what?” for “huh?”
– asks for more repetition
• Changes in response to environmental
sounds
Mapping Audiologist Needs
Information: Adjustment Indicators
• Changes in voice quality
– high pitched or “whiny” sound
– “breathless” or whispered quality
– child’s voice is louder
• close to listener
• in quiet situations
Mapping Audiologist Needs
Information: Adjustment Indicators
• Changes in loudness perception
– cannot hear sounds could hear before
• at a distance or another room
• in the car
• in noisy situations
– child complains of loudness or quality
• not louder enough
• cannot understand speech well
Mapping Audiologist Needs
Information: Adjustment Indicators
• Changes in loudness tolerance
– facial nerve stimulation
• eye twitch, squinting
• nystagmus
• pain to certain sounds
When to MAP
• Mapping should occur at parents’ or
therapist’s request
• Regularly scheduled appointments do not
allow modification as needed
– child has to function with a less than optimal
map until time of appointment
• OK to schedule, but need to get a MAP
“on demand”
Rehab Mapping Procedures
• Determine what speech perception error
pattern exist
– General errors
• high frequency cues
• vowels - particularly F2
• voicing cues
– specific errors
• voiceless stop confusion
• nasal confusion
Applying Concerns and Problems in
Rehab Mapping
• Determine which electrodes are responsible
for frequencies of error vs target
• Change MAP parameters to enhance and
highlight specific frequency differences that
will reduce misperception.
Auditory Sampling
• Auditory sampling as part of every
rehabilitation session
– document development
– document progress
– document change in performance
– document equipment malfunction
Identifying Auditory Behaviors
Auditory Skill Sampling (during interaction)
OBSERVE:
- awareness of environmental sounds
(especially those that occur regularly)
- distance listening
- increase in requests for repetition
- awareness of non-directed speech
- increase in loudness of partner’s
speech (adapt to need)
Identifying Auditory Behaviors
Auditory Skill Sampling (specific sounds)
detection vs. identification
pointing response vs. speech response
closed set vs. open set
word vs. sentence
no context vs. context
(Re)habilitation Needs
Training requires a combination of
skill development
+
dependence
analytic training
perception
bottom-up
feature-oriented
+
+
+
+
synthetic training
meaning
top-down
message-oriented
Strategies to promote carryover
Integrate listening, speech and language in
every activity.
Purpose: reinforce auditory feedback loop;
replicate normal communication process.
Strategies to promote carryover
Load sessions with multiple examples of the
target.
Purpose: to allow for the most practice possible in
a short period of time. If the child only says the
target 5 times in 30 minutes, not enough practice
has occurred.
Strategies to promote carryover
Acoustically highlight specific forms and
targets.
Purpose: to provide increased auditory
access to specific forms.
Strategies to promote carryover
Reduce level of feedback from adult direct
modeling to child self-monitoring.
Purpose: to reinforce auditory feedback
loop; hold child accountable for accurate
production and use.
Strategies to promote carryover
Reverse roles so that child has to say
something to get the adult to do
something.
Purpose: targets all objective areas
simultaneously. Child listens to adult
speech and then has to produce clear
enough speech for the adult to complete
the same task.
Strategies to promote carryover
Ask child to repeat what he/she has heard
during auditory training activities.
Purpose: speech practice; analysis of exact
acoustic information missing.
Selecting Activities:
Activities should be:
1) age appropriate
2) interesting to the child
3) interesting to the clinician
The activity is just a vehicle for facilitating
practice. It is not an end in itself.
Selecting Auditory Targets
Phoneme driven: production of final /t/
Vocabulary driven: learning the names of fruits and
vegetables
Grammar driven: using and understanding plural and
possessive markers.
Curriculum based: learning vocabulary related to
classroom routines; (100th day celebration; cast-a-spell)
Pragmatically-based: greeting and departure routines.
Easy
familiar
closed set
slow rate
segmented
context
difference
no shared features
vowel separation
Hard
unfamiliar
open set
fast rate
joined
isolated words
identification
shared features
vowel neighbors
Closed Set Activities
Bingo (letter/number)
Uno (color/number)
Hangman/Wheel of Fortune (letters)
Boggle (words out of limited letter set)
Outburst (category cue)
Battleship (paper version with targets)
Battleship
pronoun/number sentence
I
he
she
we
they
you
14
O
O
O
O
O
O
50
O
O
O
O
O
O
40
O
O
O
O
O
O
60
O
O
O
O
O
O
16
O
O
O
O
O
O
15
O
O
O
O
O
O
UNO
time designator/color-clothes
Two weeks ago
red tank top
blue skirt
purple shirt
yellow shorts
Last summer
red tank top
blue skirt
purple shirt
yellow shorts
Last year
red tank top
blue skirt
purple shirt
yellow shorts
Two days ago
red tank top
blue skirt
purple shirt
yellow shorts
Outburst
• Things you say at a restaurant
(sentences-topic clued)
• Sports you play with a ball
(single words)
• Greetings
(familiar phrases)
• Words using /st/
Closed Set Activities
Names of academic subjects
Names of cars
Chinese Menu conversation-pick one from each group
greeting-content-departure
People plus actions
-wrestlers + verb
-sports teams + verb
-golfers + verb
I went to the mall and bought…
-color + object
Open Set Activities
• Comprehension
– Map adventure
– Follow directions that change a word to
another in 20 steps.
– Crossword Clues
– Context Clues (what word would fit in
blank)
– RACKO (words are unpredictable)
– UNO (word cards)
Open Set Activities
• Any “word” game can be transformed into
a listening task by presenting the words
“listen alone”
• Speech Tracking (repeat back the
sentences accurately)
-Jokes, Who dun its?, Ripley’s Believe
it or Not, Guinness Book of
Records
Auditory Learning Strategies
1. Listen-look-listen
2. Say it clearly
acoustically highlight by:
-pausing after word
-emphasizing a specific sound
3. Give feedback regarding accuracy by:
-emphasizing incorrect word
-identifying position of incorrect
sound
4. Avoid paired comparison
-detect difference-not identification
-ineffective for carryover
Conclusion
• Language development can follow that of
typical development with
– well-mapped processor
– ongoing language intervention
– family part of process
– good listening environment