Long-term use of cochlear implant systems in paediatric recipients and factors contributing to non-use.

The aim of the present paper was to assess children's long-term use of their cochlear implant systems and to explore factors influencing the extent of daily use. The parents of 138 deaf children who had been implanted for seven years completed an annual questionnaire about the extent of their child's use of their implant system. The results revealed that seven years after implantation 115 children (83%) were wearing their implants full-time, 16 (12%) most of the time, three (2%) some of the time and four (3%) were non-users. The children were categorised into those who were full-time users (group F) and those who were not full-time users (group N). The mean age at implantation in group F was 4.4 years with a median of four whereas in group N the mean age at implantation was 5.8 years with a median of 5.5 years. This difference was highly statistically significant. There were no children who were total non-users implanted below the age of five. The predominant mode of communication was oral in group F and signed communication in group N and the difference was also statistically significant. In group F, 90 (78%) were in mainstream education, either mainstream school or a resource base in a mainstream school, whereas the respective percentage in group N was 57 per cent and this difference was statistically significant. Further investigation of those in group N shows a fluctuating pattern of use over the years prior to becoming complete non-users seven years after implantation. The four children who were complete non-users at seven years after implantation were all implanted at five and had other difficulties with all having complex family issues, three having significant other learning difficulties and one experiencing pain on stimulation. None had experienced device failure. In conclusion, this study of 138 children showed very high levels of full-time use seven years after implantation. Factors linked with full-time use seven years after implantation were early implantation, oral mode of communication and mainstream educational placement. Additional difficulties were not significant. Psycho-social issues such as family and educational support appeared to be important in facilitating continued use of the implant system. Non-use may occur after several years of use and in this group non-use followed a fluctuating pattern of use over time. The regular monitoring of device use may enable cochlear implant teams to be alert to potential non-users and to provide appropriate and timely support to the child, family and educational service.

Children with cochlear implants: the communication journey.

Cochlear implantation is now a well-established procedure for profoundly deaf children providing access to speech through hearing for many of them. Much attention has focused on which communication mode to adopt with this group of children but very little work has looked at the choices that parents make before and after cochlear implantation. This study, following on from two earlier studies, looked in depth at the experiences of 12 families. It finds that parents choose the most effective way of communicating with their child but retain as their goal, the development of oral communication skills. For many this is a journey in which different approaches are utilised at various stages in the child's development.

Speech production in deaf implanted children with additional disabilities and comparison with age-equivalent implanted children without such disorders.

OBJECTIVE: To assess the long-term speech intelligibility in implanted children with additional disorders and compare them with age-equivalent implanted children without such disorders. PATIENTS: 175 profoundly deaf children 5 years following cochlear implantation; 67 children with additional difficulties and 108 children without such difficulties. All children were implanted under 5-year-old. MAIN OUTCOME MEASURE: Speech intelligibility rating (SIR) scale that can be readily applied to young deaf children irrespective of their performance and is reliable between observers. RESULTS: Five years following implantation, 47 (70%) children with additional difficulties developed connected intelligible speech versus 104 (96%) in the control group. However, the quality of speech was quite different between the two groups, as only 11 (16%) children with additional difficulties achieved the two higher categories (intelligible to all or to people with little experience), whereas 66 (61%) children in the control group did (P<0.000001). The total number of additional disorders had the strongest correlation with the outcome. Language and communication disorders were the most important contributing factor, followed by physical, cognitive, and autistic spectrum disorders. CONCLUSION: The majority of deaf children with additional disorders develop connected intelligible speech 5 years following implantation; however, a significant proportion do not develop any speech at all. Thus a third of this group did not realise one of the most important objectives for parents of implantation. Benefit from implantation should not be restricted to speech production alone in this specific population.

Parents' views on changing communication after cochlear implantation.

We sent questionnaires to families of all 288 children who had received cochlear implants at one center in the United Kingdom at least 5 years previously. Thus, it was a large, unselected group. We received 142 replies and 119 indicated that the child and family had changed their communication approach following cochlear implantation. In 113 cases the change was toward spoken language and in 6 cases the change was toward signed communication. Parents were asked to respond to statements about communication with their deaf child, and their responses indicated that parents wanted the most effective means of communication and one that their child would find most useful in the future. Findings that emerged from parents' comments indicated that the change toward greater use of spoken language was child-led and driven by increased audition. Parents also valued the contribution of signed communication.

Evaluation of the Parental Perspective instrument for pediatric cochlear implantation to arrive at a short version.

OBJECTIVE: Evaluation of the well-known and widely used Parental Perspectives questionnaire (PP) by means of statistical analysis and exploring the possibility to develop a short version, as the instrument is often regarded as being rather lengthy with 74 questions. METHODS: One hundred and thirty parents of children participated in this study. To assess internal consistency among the PP items of the domains, Cronbach's alpha coefficients were calculated. Corrected item-total correlations were carried out to investigate the strength of individual items' associations with the construct. Factor analysis was performed to identify the statistical factors of the original PP and in exploring a revised short form PP. RESULTS: Instead of the expected 8-factor structure (eight suggested domains), factor analyses found a 15-factor structure. Nevertheless, when the proposed eight domain structure is followed, some items can be disposed of, based upon the Cronbach's alpha analyses and consistent reasoning. After reducing the number of factors based on standard criteria, a three-domain structure was shown as main concept. The cumulative variance explained by this new model was 39.4% and the final number of items in this probable revised version is 23. Reliability analyses of the new domains of the proposed short version PP (sPP) showed good internal consistency (Cronbach's alpha 0.79). The corrected item-total correlations represent strong individual items' associations with the construct as R items-total varies between 0.34 and 0.64. CONCLUSIONS: The Parental Perspectives instrument (PP) is an important tool to assess the impact of cochlear implantation of a child for the quality of life for the family and the child itself. This statistical investigation showed a possible option for development of a short form usable in prospective follow-up studies.

Does cause of deafness influence outcome after cochlear implantation in children?

OBJECTIVES: The objective of this study was to evaluate long-term speech perception abilities of comparable groups of postmeningitic and congenitally deaf children after cochlear implantation. METHODS: This prospective longitudinal study comprised 46 postmeningitic deaf children and 83 congenitally deaf children with age at implantation of < or = 5.6 years. Both groups were comparable with respect to educational setting and mode of communication and included children with additional disabilities. RESULTS: Both postmeningitic and congenitally deaf children showed significant progress after implantation. Most (73% and 77%, respectively) could understand conversation without lip-reading or use the telephone with a known speaker 5 years after implantation, whereas none could do so before implantation. At the same interval, the postmeningitic and congenitally deaf children scored a mean open-set speech perception score of 47 (range: 0-91) and 46 (range: 0-107) words per minute, respectively, on connected discourse tracking. The respective mean scores at the 3-year interval were 22 and 29 correct words per minute, respectively. None of these children could score a single correct word per minute before implantation. The progress in both groups was statistically significant. When the 2 groups were compared, there was no statistically significant difference. CONCLUSION: Postmeningitic and congenitally deaf children showed significant improvement in their auditory receptive abilities at the 3- and 5-year intervals after cochlear implantation. There was no statistically significant difference between the outcomes of the 2 groups, suggesting that, provided that children receive an implant early, cause of deafness has little influence on outcome. Although the prevalence of other disabilities was similar in both groups, for individual children, their presence may have profound impact. The study supports the concept of implantation early in life, irrespective of the cause of deafness.

Children's communication mode five years after cochlear implantation: changes over time according to age at implant.

One hundred and seventy six children who had received cochlear implants at one centre in the UK were followed up for five years post-implant. The cohort was divided into three groups by age at implant. 1: Under three years of age; 2: Between three and five; 3: Over five. Their mode of communication was noted at four key intervals - pre-implant; 1, 3 and 5 years post-implant. It was classified as either oral or sign. By five years post-implant, 83% of group 1 were using oral communication, 63.5% of group 2 and 45.1% of group 3. The results showed that the mode of communication five years post-implant is statistically related to age at implantation with more children implanted younger using an oral mode of communication (p = 0.001). Children implanted younger are more likely to change communication mode over time from sign to oral, and do so more quickly than those implanted later.

Long-term functional outcomes and academic-occupational status in implanted children after 10 to 14 years of cochlear implant use.

OBJECTIVES: To assess a group of consecutively implanted children over 10 years after implantation with regard to implant device use and function, speech perception, and speech intelligibility outcomes; and to document current academic or occupational status. STUDY DESIGN: A prospective longitudinal study assessing device function, device use, speech perception, speech intelligibility, and academic/occupational status of implanted deaf children. SETTING: Pediatric tertiary referral center for cochlear implantation. METHODS: The auditory performance and speech intelligibility development of 30 profoundly deaf children were rated before cochlear implantation and at 5 and 10 years after implantation using the Categories of Auditory Performance and the Speech Intelligibility Rating. The academic and/or occupational status of the participants after 10 years of implant experience was documented. All children received a Nucleus multichannel cochlear implant between the ages of 2.5 and 11 years (mean age at implantation, 5.2 yr). Implant experience ranged from 10 to 14 years of use. RESULTS: After 10 years of implant experience, 26 subjects (87%) reported that they always wore their device; 2 subjects (7%), frequently; and 1 subject (3%), occasionally. Only one child had discontinued use of his device. After 10 years of implant use, 26 (87%) of the children understood a conversation without lip reading and 18 (60%) used the telephone with a familiar speaker. Ten years after implantation, 23 (77%) of the subjects used speech intelligible to an average listener or a listener with little experience of a deaf person's speech. One-third to one-half of the implanted children continued to demonstrate improvements at 5 to 10 years of implant use. Of the 30 implanted children, 8 (26.7%) experienced nine device failures. The length of time from identification of the first faulty electrode to reimplant surgery ranged from 2 weeks to 5.5 years, as several failures were gradual or intermittent. However, all children were successfully reimplanted. At the end of the study (10-14 yr after implantation), 19 subjects were in secondary school for children aged 11 to 16 years: 6 were in mainstream schools, 7 were in specialist hearing-impaired units attached to a mainstream secondary school, and 6 were in schools for the deaf. Of the remaining 11 subjects, 4 were in college studying vocational subjects, 2 were in a university studying for a bachelor's degree, 3 were working full-time, 1 was working and going to a university part-time, and 1 was a full-time mother of two young children. CONCLUSION: All but 1 of the 30 implanted children continue using their devices 10 to 14 years after implantation, showing significant progress in speech perception and production. Device failure was frequent, but successful reimplantation occurred in all cases. One-third to one-half of the implanted children in this study continued to demonstrate improvements at 5 to 10 years of implant use. All children are studying or working and are actively involved in their local communities. The results suggest that cochlear implantation provides long-term communication benefit to profoundly deaf children that does not plateau for some subjects even after reimplantation. This study further indicates that cochlear implant centers need the structure and funding to provide long-term support, counseling, audiologic follow-up, rehabilitation, and device monitoring to implanted children.

Young deaf children with hearing aids or cochlear implants: early assessment package for monitoring progress.

BACKGROUND: Very few assessment measures exist for evaluating progress in young deaf children with hearing aids and cochlear implants. OBJECTIVE: To introduce and describe an early assessment package that covers auditory perception, communication/language development, and speech production in very young deaf children. MAIN OUTCOME MEASURES: Seven of the assessment measures (Listening Progress Profile, Categories of Auditory Performance, Tait Video Analysis, Stories-Narratives Assessment Procedure, Profile of Actual Linguistic Skills, Speech Intelligibility Rating, and the Profile of Actual Speech Skills) have been specifically developed at the Nottingham Cochlear Implant Programme, and a further one (Meaningful Auditory Integration Scale) was modified for use within the package. Moreover, two commercially available tests (Pragmatics Profile of Everyday Communication Skills and Preschool Language Scale) are included to complete the package. METHODS: The present paper describes each measure, how to use it, and its time frame. In addition, two case studies demonstrate the usefulness of the package as a whole. RESULTS AND CONCLUSIONS: The Nottingham Early Assessment Package (NEAP) offers a framework with which to assess in young deaf children the use of audition and language and communication in real-life situations. Being simple, reliable, and time effective can be used in everyday clinical practice. NEAP is innovative in design and offers a structured approach to monitor very young deaf children, both in short and long term. In addition, it allows the identification of additional problems and areas of difficulty as well as specific abilities and skills. This enables the clinician to determine appropriate intervention strategies.

Parents and their cochlear implanted child: questionnaire development to assess parental views and experiences.

OBJECTIVES: To test the reliability of a validated closed-format questionnaire assessing parental views following cochlear implantation of their child. DESIGN: Parents were surveyed using a closed-format questionnaire developed in earlier work. The same parents were surveyed 1 month later and responses compared. Test-retest reliability was thereby assessed. SETTING: Tertiary referral Pediatric Cochlear Implant Centre in the UK. SUBJECTS AND METHODS: The parents of 20 children who had been born deaf or were deafened by age 3 years and who had been implanted for at least 2 years were drawn at random from patient lists. Parents were surveyed using a closed-format questionnaire whose validity had been previously assessed and re-surveyed 1 month later. Responses over time were compared. RESULTS: For the majority of items in the questionnaire, the replication of the item would lead to the same response on at least 95% of occasions. The text of the closed-format questionnaire is reproduced in full. CONCLUSION: This validated closed-format questionnaire appears to be unique in respect of cochlear implantation, being based explicitly on issues thought important by the parents. The high test-retest reliability indicates that it is capable of eliciting parental views in a meaningful manner. This information that is not currently available by other means can then be used as part of an overall assessment of outcomes, to inform efforts aimed at quality improvement as well as demonstrating accountability to purchasers and policymakers. Moreover, a wider use of this instrument can result in valid comparisons of outcomes among different cochlear implant centres.

The educational settings of profoundly deaf children with cochlear implants compared with age-matched peers with hearing aids: implications for management.

The educational settings of 42 implanted profoundly deaf children 3 years after implantation were compared with the respective settings of 635 age-matched severely deaf and 511 profoundly deaf children with hearing aids. All implanted children received their implants before beginning school. The results revealed that 3 years after implantation. 38% (16 children) of the implanted profoundly deaf children attended mainstream schools, whereas 57% (24 children) were in a unit, or special class, in a mainstream school, and 5% (two children) were in schools for the deaf. With regard to the age-matched profoundly deaf children with hearing aids, 12% (63 children) attended mainstream schools, whereas 55% (281 children) were in a unit of a mainstream school, and 33% (167 children) were in schools for the deaf. In the group of age-matched severely deaf children, 38% (239 children) attended mainstream schools, whereas 51% (326 children) were in a unit of a mainstream school, and 11% (70 children) were in schools for the deaf. Statistical analysis revealed a highly significant difference between the educational placement of implanted children and hearing-aided profoundly deaf children (p<0.00001), whereas there was no statistically significant difference between implanted children and hearing-aided severely deaf children. In conclusion, implanted profoundly deaf children who have received their implants before beginning school have the same profile of educational placement as aided severely deaf children rather than aided profoundly deaf children of the same age in the UK. This is likely to have significant implications for the future management of profoundly deaf children and to influence future planning of educational support services.