Impact of reading and writing skills on academic achievement among school-aged hearing-impaired children

Impact of reading and writing skills on academic achievement among school-aged hearing-impaired children

International Journal of Pediatric Otorhinolaryngology 126 (2019) 109619 Contents lists available at ScienceDirect International Journal of Pediatri...

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International Journal of Pediatric Otorhinolaryngology 126 (2019) 109619

Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl

Impact of reading and writing skills on academic achievement among school-aged hearing-impaired children

T

Akiko Sugayaa,*, Kunihiro Fukushimab,c, Soshi Takaod, Norio Kasaie, Yukihide Maedaa, Akie Fujiyoshib,c, Yuko Kataokaa, Shin Kariyaa, Kazunori Nishizakia a

Department of Otolaryngology, Head and Neck Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Japan Hayashima Clinic, Dermatology & Otolaryngology, Japan c KIDS*FIRST, Child Development Support office, Japan d Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Japan e Department of Otolaryngology, National Sanatorium Oku-Komyoen, Japan b

ARTICLE INFO

ABSTRACT

Keywords: Hearing impairment School age Reading and writing difficulties Academic achievement

Objectives: Reading and writing skills are important for hearing-impaired children since these skills help them to develop their language skills, but the prevalence of reading/writing difficulties and its effects on language development aspects among them are unclear. In this study, we identified language development features and demographic factors of Japanese hearing-impaired children diagnosed as having reading/writing difficulties. Methods: We analyzed data from a total of 546 sever-to-profound pre-school and elementary school hearingimpaired children for this study. Children with reading/writing difficulties (Group A) were defined as children obtaining low scores (−1.5 SD compared to others in the same grade) in the Screening Test of Reading and Writing for Japanese Primary School Children (STRAW), and we compared other language development features (communication ability, vocabulary, syntax and academic achievement) and demographic factors to those of hearing-impaired children with normal reading and writing skills (Group B). We assessed language development domains as outcomes using the Assessment of Language Development for Japanese Children (ALADJIN) package, and analyzed the results stratified by age groups (5–6, 7–8, 9–10, and 11–12 years) using multiple regression analyses. Results: The prevalence of reading/writing difficulties was 20.1% among the participants. Almost all point estimates in each language development domain showed better odds ratios (OR) except Criterion Referenced Test -II (CRT-II) mathematics in 11- to 12-year-olds in fully-adjusted models. Among 9- to 10-year-olds, the ORs (95% confidence interval) for fair academic achievement measured by CRT-II were 2.60 (1.09–6.20) for Japanese and 3.02 (1.29–7.11) for mathematics in Group B, even after adjusting for possible confounding factors. Conclusions: Reading and writing are important for language development of hearing-impaired children, especially for academic achievement during the middle phase of elementary school. Screening for reading/writing difficulties is important for appropriate intervention and to prevent language and academic delays among hearing-impaired children.

1. Introduction Prelingual hearing impairment has a lifelong impact, affecting language development, and resulting in diminished quality of life (QOL) of the hearing-impaired children. Communication problems and low academic achievement restrict individuals from entering future education stages or job opportunities. Early hearing detection and intervention (EHDI) is now accepted as a golden standard for prelingual

hearing-impaired children, i.e., new born hearing screening [1] and cochlear implantation [2] after early hearing aids (HAs) are newly widely implemented early intervention procedures that improve the lives of hearing-impaired children. The language abilities of hearingimpaired individuals have dramatically improved after EHDIs into communities [3]. Reading and writing skills seem to hold special importance for hearing-impaired children. Visual information or cues are important for

* Corresponding author. Department of Otolaryngology, Head and Neck Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan. E-mail address: [email protected] (A. Sugaya).

https://doi.org/10.1016/j.ijporl.2019.109619 Received 1 April 2019; Received in revised form 29 July 2019; Accepted 30 July 2019 Available online 02 August 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.

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education of not only sign language users, but also for severe-to-profound hearing-impaired children using HAs or cochlear implants (CI). Reading and writing skills are considered essential for academic achievements [4], since the education efficacy is affected by the usage of reading materials. Reports have shown that mastering reading and writing at an early stage promotes language development among Japanese hearing-impaired children [5–7]. Most hearing-impaired children learn reading and writing skills in their pre-school age, and these skills help them expand their knowledge from written materials; however, some children manifest reading/writing difficulties for their developmental stage. Hiragana and Katakana consist each of 46 characters that form the two Japanese syllabaries collectively called as Kana. A syllabary is a set of symbols representing syllables or morae (sg. mora)—units of sound used in phonology [8] for Kana or Japanese language. Hiragana makes up Japanese words, and Katakana creates words of foreign origin, and Japanese children start to learn Hiragana in the early year in pre-school. On the other hand, Kanji is an ideogram, and children learn Kanji and Katakana during their elementary school years. Unfortunately, some children present special difficulties in reading and writing. The prevalence of these reading/writing difficulties differs depending to the language system. For example, the Japanese language is known to be complicated by reading/writing difficulties to a smaller extent than other languages, since graphene-phoneme correspondence is one-to-one in Japanese [9]. In fact, among Japanese children with normal-hearing, the proportion of those with reading/writing difficulties are 0.2% for reading and 1.6% for writing in Hiragana, 1.4% and 3.8% for Katakana, and 6.9% and 6% for Kanji [10]. Reading/writing difficulties is considerably more frequent in northern Europe or North America than in Southern Europe or in Japan [9], and adolescents with reading/writing difficulties are reported to not only struggling with this but also experiencing low self-rated health [11]. Even though reading/writing difficulties have a severe impact on language development of hearingimpaired children, its frequency during pre-school and elementary school years is unclear. We designed a study to define the prevalence of reading/writing difficulties among Japanese hearing-impaired children, and to compare their language development and their affected language domains in contrast to those in hearing-impaired children without reading/writing difficulties. Our Research on Sensory and Communicative Disorders (RSCD) [12] project was a multicenter study conducted in Japan from 2007 to 2012 involving 4- to 12-year-old severe-to-profound hearing-impaired children, who were studying at schools for the deaf, in hard-of-hearing classrooms, as well as in mainstreaming schools and, who were wearing HAs and/or CIs. The children who participated in this RSCD study underwent language development tests called the Assessment of Language Development for Japanese Children (ALADJIN) that cover a wide range of language domains, including receptive/productive vocabulary, syntax, pragmatics, and others [12]. Reading and writing skills for Japanese characters (Hiragana, Katakana, and Kanji) were tested by one of the ALADJIN tests called Screening Test of Reading and Writing for Japanese Primary School Children (STRAW) [10,13], which is standardized to screen for ageinappropriate development of reading and writing skills in Japanese. We made an operational definition for reading/writing difficulties as obtaining low scores (−1.5SD) in each questionnaire of STRAW, and first described the prevalence of reading/writing difficulties among school-aged, severe-to-profound hearing-impaired Japanese children, and then investigated their demographic characteristics. Finally, we compared the development of each language domain between hearingimpaired children with or without reading/writing difficulties in order to analyze the impact of them on other language domains. We used −1.5SD as a cutoff point in each questionnaire of STRAW based on the report of Uno et al. [10]. This reference point is generally used in fields of psychology and education in Japanese language [14],

and by using this point, we aimed to detect reading and writing difficulties in children with relatively permissive criteria for early detection and intervention to children with such disorders. 2. Participants and methods 2.1. Participants This study involved hearing-impaired children who were part of the RSCD project. Participants met the following inclusion criteria: (1) Age 4–12 years during the research period (April 2009 to March 2010), (2) prelingual and severe-to-profound hearing impairment (> 70 dB on average), and (3) ability to complete several language tests. In total, 638 children participated in the RSCD project. After excluding children who had other disabilities such as low birth weight (< 1800 g) (n = 15), mental disabilities (scores of Raven's Colored Progressive Matrices RCPM [15] < −2SD) (n = 9), and Autism Spectrum Disorder (ASD) (PARS > 11) (n = 68), we restricted our analysis to only those from 5 years of age to those in 6th grade in elementary school (because the language data were only examined in these children). In the end, we analyzed data from 546 children. The Institutional Review Boards of all affiliated institutions approved our study design. 2.2. Methods 2.2.1. Exposure measurements We used STRAW to screen for age-inappropriate development of reading and writing skills in Japanese. We made an operational definition as reading/writing difficulties combined group with children obtaining low scores (−1.5 SD compared to children in the same grade, as mentioned in the introduction) in each STRAW questionnaire, and included the children in Group A. Hearing-impaired children who demonstrated normal reading and writing skills were included in Group B. 2.2.2. Outcome measurements: language assessments An experienced audiologist or speech language pathologist tested participants of this study on a face-to-face meeting in a sound-attenuated chamber while the children wore their usual hearing devices (i.e., HAs or CIs). The children underwent a series of tests from the ALADJIN [12] package including the following: A test for questionanswer interaction development (TQAID) [16] measuring communication ability, the Word Fluency Test (WFT [17]) measuring productive vocabulary, the Picture Vocabulary Test-Revised (PVT-R [18]) as well as the Standardized Comprehension Test of Abstract Words (SCTAW [19]) measuring receptive vocabulary, both parts of the Syntactic processing Test for Aphasia (STA [20]) measuring productive and receptive syntax, and the Criterion Referenced Test-II (CRT-II) [21] measuring academic achievement in Japanese and mathematics. Both the SCTAW and CRT-II were used with school-aged children only. We converted the scores of ALADJIN into z scores, that is, the number of standard deviations by which the scores differed from the mean scores in each grade. In addition, we calculated the standard scores (SS = 50 + 10 × < z score >). We calculated means and standard deviations from the language scores obtained during the baseline RSCD study [12], and we dichotomized the language development scores into fair/poor language development corresponding scores lower or higher than 55, respectively. 2.2.3. Covariates We also distributed questionnaires to caregivers, soliciting information on participants’ age, gender, use of CI (yes/no), use of sign language (yes/no), and help of the caregivers to the child (familial involvement). We used 10 questions to assess familial involvement including the following: (1) Do you play with your child? (2) Do you talk with your child about his/her future? (3) Do you talk with your child 2

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about social concerns? (4) Do you participate in parent–teacher association activities? We asked caregivers to select one of four Likert scales for each question: almost always (=1), sometimes (=2), rarely (=3), or almost never (=4). We dichotomized the total scores for familial involvement (≤20 and > 20). In order to verify the answers from caregivers, we also distributed similar questionnaires to the teachers, audiologists, or speech pathologists that routinely followed up the targeted children.

Table 1 Demographic characteristics and language development scores among 546 hearing-impaired children (5-year-olds to 6th graders of elementary school students) of the RSCD project, in Japan. demographic characteristics

2.3. Statistical analysis

Gender

We considered each language development domain (TQAID, WFT, PVT-R, SCTAW, STAp, STAc, CRT-II j, and CRT-II m) as an outcome and applied logistic regression analysis stratified by age groups (5–6, 7–8, 9–10, and 11–12 years old). We adjusted the data for differences in gender, use of CI, use of sign language, and family involvement in multiple regression analyses (raw, gender-adjusted, and fully-adjusted models). We considered all p < 0.05 as statistically significant and calculated odds ratios and 95% confidential intervals. We performed all statistical analyses using the STATA 14.1SE software on a Windows 7 personal computer.

Cochlear implant use Use of sign language Family involvement

reading/writing difficulties combined group Group A

male female unknown yes no yes no ≦20 > 20

Language development Communication ability TQAID Productive vocabulary WFT Receptive vocabulary PVT-R SCTAW Syntax STA p STA c Academic achievement CRT- II j CRT -II m Test age (months)

3. Results 3.1. Demographic factors From the results of STRAW, 436 children (79.9%) had normal in reading and writing skills (Group B), whereas 110 children (20.1%) were diagnosed as having reading/writing difficulties (Group A). Table 1 shows the differences in demographic characteristics between both groups of children. We found no differences in gender, use of CI or sign language, or family involvement between these two groups.

Normal reading/writing group Group B

n

%

n

%

60 50

54.5 45.5

58 52 61 49 86 24

52.7 47.3 55.5 44.5 78.2 21.8

205 222 9 192 244 211 222 358 78

47.0 50.9 2.10 44.0 56.0 48.7 51.3 82.1 17.9

mean

SD

mean

SD

46.05

10.90

51.93

8.69

46.17

8.93

51.10

10.05

44.40 45.32

9.86 9.64

51.57 51.90

9.49 9.55

44.61 44.70

10.63 10.90

51.63 51.63

9.23 9.57

46.36 47.01 106.84

11.10 10.90 21.58

52.93 52.86 93.59

7.72 7.63 27.99

TQAID: Test for question-answer interaction development WFT: Word Fluency Test PVT-R: Picture Vocabulary Test-Revised SCTAW: Standardized Comprehension Test of Abstract Words STA p: Syntactic processing Test for Aphasia (production) STA c: Syntactic processing Test for Aphasia (comprehension) CRT-II j: Criterion Referenced Test-II (Japanese) CRT-II m: Criterion Referenced Test-II (mathematics)

3.2. Language assessments In all language tests listed below, the average score of Group B (hearing-impaired children without reading/writing difficulties) were better than those of Group A (hearing-impaired children with reading/ writing difficulties) as shown in Table 1. Tables 2a, 2b, 2c, and 2d show the results of the multiple logistic regression analyses, odds ratios (ORs) for fair language development of each domain (the reference category was Group B), and the corresponding 95% confidence intervals. Hearing-impaired children with normal reading and writing skills between 9 and 10 years of age showed fair language development (significant ORs, 2.60 to 11.80) except for productive vocabulary, measured by WFT. Among children from 7 to 8 years of age, the receptive vocabulary (PVT-R) and syntax (STAc) were significantly better in children without reading/writing difficulties than those in children with reading/writing difficulties. Among children from 11 to 12 years of age, the communication ability (TQAID) and receptive vocabulary (SCTAW) were significantly better in those without reading/writing difficulties than in those affected by it.

Table 2a Odds ratios and 95% confidence intervals for fair language development among 5- to 6-year-old hearing impaired children without reading/writing difficulties and those with it. OR(95%confidence interval) Raw model Communication ability TQAID 1 (omitted) Productive vocabulary WFT 1 (omitted) Receptive vocabulary PVT-R 3.32 (0.41–27.06) SCTAW NA Syntax STA p 1 (omitted) STA c 1 (omitted) Academic achievement CRT-II j NA CRT-II m NA

3.2.1. Communication ability The odds ratios for TQAID was 3.16 (95% Confidence Interval, 1.30–7.71) in 9-to 10-year-olds, and 5.21 (1.35–20.11) in 11- to 12year-olds indicating significant better communication ability in Group B than in Group A in fully-adjusted models.

Gender-adjusted model

Fully-adjusted model

1 (omitted)

1 (omitted)

1 (omitted)

1 (omitted)

3.20 (0.39–26.06) NA

3.77 (0.45–31.39) NA

1 (omitted) 1 (omitted)

1 (omitted) 1 (omitted)

NA NA

NA NA

Gender, cochlear implant use, use of sign language, and family involvement were adjusted in fully adjusted models.

3.2.2. Vocabulary development For WFT test, point estimates of ORs for fair language development were elevated (1.54–2.77 in fully-adjusted models) among children without reading/writing difficulties (Group B) compared to those in children with reading/writing difficulties (Group A), but the differences lacked statistical significance.

The ORs for PVT-R were 6.62 (95% Confidence Interval, 1.43–30.53) in 7- to 8-year-olds and 11.80 (3.96–35.19) in 9- to 10year-olds, indicating significantly better vocabulary development in Group B than in Group A in fully-adjusted models. 3

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The ORs for SCTAW were 6.01 (2.14–16.91) in 9- to 10-year-olds and 12.34 (1.45–104.81) in 11- to 12-year-olds in fully-adjusted models, indicating significantly better abstract vocabulary development in Group B than in Group A in fully-adjusted models.

Table 2b Odds ratios and 95% confidence intervals for fair language developments among 7- to 8-year-old hearing-impaired children without reading/writing difficulties and those with it. OR (95% confidence interval) Raw model Communication ability TQAID 2.08 (0.84–5.12) Productive vocabulary WFT 2.50 (0.79–7.92) Receptive vocabulary PVT-R 6.63 (1.48–29.63) SCTAW 2.95 (0.80–10.83) Syntax STA p 2.79 (0.97–7.98) STA c 5.52 (1.78–17.14) Academic achievement CRT-II j 2.01 (0.57–7.14) CRT-II m 4.00 (1.04–15.38)

Gender-adjusted model

Fully-adjusted model

2.04 (0.83–5.06)

1.53 (0.58–4.08)

2.51 (0.79–8.00)

2.29 (0.70–7.52)

6.61 (1.47–29.67) 2.89 (0.78–10.67)

6.62 (1.43–30.53) 2.81 (0.75–10.50)

2.88 (1.00–8.26) 5.51 (1.77–17.14)

2.65 (0.89–7.87) 5.16 (1.62–16.46)

2.34 (0.62–8.79) 4.16 (1.07–16.17)

2.09 (0.54–8.05) 3.31 (0.81–13.47)

3.2.3. Syntax development The OR for STA production was 4.44 (95% Confidence Interval, 1.63–12.13) in 9- to 10-year-olds, indicating significantly better productive syntactic development in Group B than in Group A in fullyadjusted models. The ORs for STA comprehension were 5.16 (1.62–16.46) in 7- to 8year-olds and 3.74 (1.43–9.77) in 9- to 10-year-olds in fully-adjusted models, indicating significantly better receptive syntactic development in Group B than in Group A in fully-adjusted models. 3.2.4. Academic achievement The ORs for CRT-II Japanese and mathematics in 9- to 10-year-olds were 2.60 (95% Confidence Interval, 1.09–6.20) and 3.02 (1.29–7.11), respectively, indicating significant better academic achievement in Group B than in Group A in fully-adjusted models.

Gender, cochlear implant use, use of sign language, and family involvement were adjusted in fully-adjusted models.

4. Discussion

Table 2c Odds ratios and 95% confidence intervals for fair language developments among 9- to 10-year-old hearing-impaired children without reading/writing difficulties and those with it.

To the best of our knowledge, this is the first study describing the prevalence of reading/writing difficulties among Japanese hearingimpaired children, as well as the first one presenting the characteristics of the language development of Japanese hearing-impaired children with reading/writing difficulties. In reports of other countries, educational significant disabilities exist in 25–33% [22] of hearing-impaired children, and among them, learning disabilities are the most common complications. On the other hand, we observed reading/writing difficulties in about 20% of the hearing-impaired children, which is relatively high compared to that present in normal-hearing children. Japanese language is known to complicate reading/writing difficulties to a lesser extent than other languages; and in fact, among Japanese normal-hearing children, the proportion of reading/writing difficulties is reported to be 0.2% for reading and 1.6% for writing in Hiragana, 1.4% and 3.8% for Katakana, and 6.9% and 6% for Kanji [10]. Therefore, we were surprised to see the high proportion of children with reading/writing difficulties among the Japanese hearing-impaired children. Different hypotheses on how reading and writing disorders are provoked in children during their development exist, and one of them is the phonological disorder hypothesis [23], that is, a dysfunction at an early stage of sound-encoding. Prelingual hearing impairments may negatively influence this sound-encoding, and the high proportion of reading/writing difficulties among hearing-impaired children may be due to this. On the other hand, many Japanese hearing-impaired children are provided opportunities to learn reading and writing during their early life (during their pre-school years) and some hearing-impaired children acquire these skills earlier than their normal-hearing peers. Since hearing-impaired children receive early intervention using letters, this relatively high proportion of reading/writing difficulties among hearing-impaired children should not be overlooked. The results of our logistic regression analyses suggest that reading and writing skills may strongly contribute to the language development in the middle stages of elementary school. Moreover, the SCTAW, which predicts academic achievement [12] showed a high ORs among 9- to 10-year-old and 11- to 12-year-old hearing-impaired children without reading/writing difficulties as compared to those in children with reading/writing difficulties, suggesting the importance of reading and writing skills to academic achievement during these grades in elementary school. Since reading/writing difficulties is related to language development, especially for academic achievement, early detection and early intervention are required. The mechanisms by which reading/writing difficulties affects

OR (95% confidence interval) Raw model Communication ability TQAID 3.27 (1.44–7.45) Productive vocabulary WFT 1.59 (0.64–3.91) Receptive vocabulary PVT-R 9.76 (3.51–27.13) SCTAW 5.20 (1.94–13.98) Syntax STA p 3.25 (1.36–7.77) STA c 3.64 (1.48–8.97) Academic achievement CRT-II j 2.69 (1.21–5.95) CRT-II m 3.09 (1.38–6.91)

Gender-adjusted model

Fully-adjusted model

3.55 (1.53–8.26)

3.16 (1.30–7.71)

1.63 (0.66–4.03)

1.54 (0.61–3.87)

11.77 (4.04–34.33) 5.84 (2.12–16.08)

11.80 (3.96–35.19) 6.01 (2.14–16.91)

4.63 (1.73–12.40) 4.05 (1.61–10.20)

4.44 (1.63–12.13) 3.74 (1.43–9.77)

2.82 (1.26–6.33) 3.01 (1.33–6.74)

2.60 (1.09–6.20) 3.02 (1.29–7.11)

Gender, cochlear implant use, use of sign language, and family involvement were adjusted in fully-adjusted models. Table 2d Odds ratios and 95% confidence intervals for fair language developments among 11- to 12-year-old hearing-impaired children without reading/writing difficulties and those with it. OR (95% confidence interval) Raw model Communication ability TQAID 5.12 (1.39–18.85) Productive vocabulary WFT 2.53 (0.52–12.32) Receptive vocabulary PVT-R 1.52 (0.52–4.45) SCTAW 11.45 (1.43–91.73) Syntax STA p 3.00 (0.90–10.06) STA c 2.21 (0.72–6.80) Academic achievement CRT-II j 1.62 (0.57–4.61) CRT-II m 0.98 (0.36–2.65)

Gender-adjusted model

Fully- adjusted model

5.14 (1.35–19.66)

5.21 (1.35–20.11)

2.83 (0.57–14.10)

2.77 (0.53–14.54)

1.16 (0.64–6.22) 10.86 (1.34–88.26)

2.42 (0.75–7.80) 12.34 (1.45–104.81)

2.81 (0.81–9.72) 2.18 (0.68–6.96)

2.72 (0.76–9.66) 2.50 (0.75–8.31)

1.47 (0.490–4.39) 0.91 (0.32–2.59)

1.45 (0.48–4.37) 0.98 (0.33–2.91)

Gender, cochlear implant use, use of sign language, and family involvement were adjusted in fully-adjusted models.

4

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language development are unclear. Studies on hearing-impaired children using CIs have shown that CI user presented a cognitive-linguistic profile very similar to those of hearing peers [24], but language development is poor when phonological processing impairments are present with hearing loss [25], and this may be one of the causes of language delay. One the other hand, the diminished language stimulation using reading materials due to insufficient reading and writing skills, may accentuate language delays, and this may be another cause of language delay. Our results suggest that in order to prevent language delays reading and writing skills should be screened using the STRAW test during the early elementary school years, and that implementing appropriate interventions may improve the future QOL of school age hearing-impaired children with reading/writing difficulties.

Statement of grant or other financial support We thank all the participants in this study including the children, parents, collaborators and staff of the Research on Sensory and Communicative Disorders (RSCD) project the Association of Technical Aid (Tokyo Japan). This work was a part of an RSCD project supported by a grant from the Ministry of Health, Welfare, and Labor, and Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number 15K20209 and 18K16890. Acknowledgments This work was a part of the RSCD project, supported by a grant from the Ministry of Health, Labor and Welfare of Japan, and Japan Society for the Promotion of Science (JSPS) KAKENHI Grant (Number 15K20209 and 18K16890). We would like to express our deepest appreciation to all the participants in this study, particularly to the children and their caregivers. Also, we would like to thank Miss Tomoko Taguchi, and all the collaborators of this study.

4.1. Study limitations We are aware of our study's limitations. First, the number of 4- to 5year-old children was small in this dataset, because not enough STRAW tests were administered at these ages. Therefore, we could not estimate many of ORs for this age category. Second, the study design was crosssectional, so caution needs to be exerted to avoid false causation interpretations, for example some language developments may not be the result of better STRAW scores among the hearing-impaired children. In the future, a longitudinal study should determine the temporal association and causation between STRAW scores and other aspects of language development. There are other test batteries which can evaluate reading and writing abilities, such as, Kaufman Assessment Battery for Children (KABC) measuring reading and writing abilities as well as reading age under 18 years old, Early Literacy Check (ELC) measuring reading of Hiragana among 2-3rd grade of elementary school, and Comprehensive Assessment of Reading Domains (CARD) measuring reading skills from 1–6th grade of elementary school [14]. In the present study protocol, STRAW is the only test battery that can test Japanese reading and writing according to the three notations of Hiragana, Katakana, and Kanji. STRAW, however, is not enough to evaluate reading speed which is related to reading and writing abilities of children. The revised edition of this test battery named STRAW-R [14], includes rapid reading task, and further study using STRAW-R must have been performed to diagnose more precise status of hearingimpaired children with reading/writing difficulties.

Appendix A. Supplementary data Supplementary data related to this article can be found at https:// doi.org/10.1016/j.ijporl.2019.109619. References [1] K. Fukushima, N. Mimaki, S. Fukuda, K. Nishizaki, Pilot study of universal newborn hearing screening in Japan: district-based screening program in Okayama, Ann. Otol. Rhinol. Laryngol. 117 (2008) 166–171. [2] A. Sugaya, K. Fukushima, N. Kasai, Y. Kataoka, Y. Maeda, R. Nagayasu, N. Toida, S. Ohmori, A. Fujiyoshi, T. Taguchi, R. Omichi, K. Nishizaki, Impact of early intervention on comprehensive language and academic achievement in Japanese hearing-impaired children with cochlear implants, Int. J. Pediatr. Otorhinolaryngol. 79 (2015) 2142–2146. [3] S. Ohmori, A. Sugaya, N. Toida, E. Suzuki, M. Izutsu, T. Tsutsui, Y. Kataoka, Y. Maeda, K. Fukushima, K. Nishizaki, Does the introduction of newborn hearing screening improve vocabulary development in hearing-impaired children? a population-based study in Japan, Int. J. Pediatr. Otorhinolaryngol. 79 (2015) 196–201. [4] A.E. Geers, H. Hayes, Reading, writing, and phonological processing skills of adolescents with 10 or more years of cochlear implant experience, Ear Hear. 32 (2011) 49–59. [5] M. Notoya, S. Suzuki, The role of written language in language development of the hearing-impaired (written in Japanese), Jpn. J. Logopedics Phoniatrics 25 (1984) 140–146. [6] S. Suzuki, M. Notoya, M. Furukawa, T. Miyazaki, R. Umeda, Language achievements of hearing-impaired children receiving written language instruction from an early age (written in Japanese), Jpn. J. Logopedics Phoniatrics 29 (1988) 280–286. [7] T. Kobayashi, M. Notoya, M. Furukawa, Long-term progress in reading abilities in hearing-impaired children trained by the kanazawa method (written in Japanese), Jpn. J. Logopedics Phoniatrics 44 (2003) 298–303. [8] https://www.lingualift.com/blog/japanese-scripts-hiragana-katakana/Reference to a website. [9] S.D. Lindgren, E. de Renzi, L.C. Richman, Cross-national comparisons of developmental dyslexia in Italy and the United States, Child Dev. 56 (1985) 1404–1417. [10] A. Uno, T.N. Wydell, N. Haruhara, M. Kaneko, N. Shinya, Relationship between reading/writing skills and cognitive abilities among Japanese primary-school children: normal readers versus poor readers(dyslexics), Read. Writ. 22 (2009) 755–789. [11] M.Z. Kjeldsen, C.M. Stapelfeldt, L. Lindholdt, T. Lund, M. Labriola, Reading and writing difficulties and self-rated health among Danish adolescents: cross-sectional study from the FOCA cohort, BMC Public Health 19 (2019) 537. [12] K. Fukushima, N. Kasai, K. Omori, A. Sugaya, A. Fujiyoshi, T. Taguchi, T. Konishi, S. Sugishita, W. Takei, H. Fujino, T. Ojima, K. Nishizaki, Assessment package for language development in Japanese hearing-impaired children (ALADJIN) as a test battery for the development of practical communication, Ann Otol Laryngol 121 (2012) 3–15. [13] K. Suzuzki, A. Uno, N. Haruhara, M. Kaneko, T.N. Wydell, N. Awaya, J. Kozuka, T. Goto, Characteristics of Hiragana and Katakana writing in children with developmental dyslexia, evaluated by the screening test of reading and writing for Japanese primary school children (STRAW) (written in Japanese), Jpn. J. Logopedics Phoniatrics 51 (2010) 1–11. [14] A. Uno, STRAW-R: standardized test for assessing the reading and writing attainment of Japanese children and adolescent: accuracy and fluency (written in Japanese), Jpn J Pediatr Med 50 (2018) 1422–1425. [15] A. Uno, N. Shinya, N. Haruhara, M. Kaneko, Raven's coloured progressive matrices

4.2. Clinical implications and future directions Few studies on the cognitive ability and on interventions in children with developmental reading and writing disabilities combined with hearing impairment exist [26,27]. If early interventions are useful, reading/writing difficulties screening using STRAW is essential. 5. Conclusion Even after adjusting for the presence of autistic disorders or nonverbal intelligence, obstacles to reading and writing at the character or word levels may significantly influence the receptive vocabulary, syntax and academic achievement of school-aged hearing-impaired children, especially during the intermediate years. We found no associations between these developmental outcomes, and the use of CIs or the use of sign language, but reading and writing disorders exist among hearing-impaired children. Early screening and intervention are necessary for children who manifest reading and writing disorders among the hearing-impaired children. 5

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