- Email: [email protected]
or behavioral disorders: retrospective analysis
International Congress Series 1273 (2004) 277 – 280
www.ics-elsevier.com
Performance of implanted children with developmental delays and/or behavioral disorders: retrospective analysis Margaret Winter*, Karen C. Johnson, Annie Vranesic Children’s Auditory Research and Evaluation (CARE) Center, House Ear Institute, 2100 W. Third St., Los Angeles, CA 90057, United States
Abstract. Deaf children with additional disabilities are receiving cochlear implants with increasing frequency. Although it has not been the routine policy of the House Ear Institute/House Ear Clinic team to implant children with developmental delays and/or behavioral disorders, a small number of our implanted children have shown evidence of such disabilities, either before or after implantation. Retrospective analysis of the post-implant performance and educational status of 10 of these children shows that most have made only minimal gains in functional oral communication ability, despite appropriate educational and therapy services. Although we believe that some children with developmental delays or disorders may benefit from implantation, these gains may not be tapped using our current metrics of post-implant performance. Furthermore, we have found that the educational programs available to many implanted children with additional needs do not adequately support both implant-facilitated language growth and the development of alternative forms of communication. D 2004 Elsevier B.V. All rights reserved. Keywords: Cochlear implants; Deaf children; Developmental delay; Behavioral disorder
1. Introduction The House Ear Institute/House Ear Clinic program has been slow to embrace the routine cochlear implantation of children with developmental and/or behavioral delays and disorders. Rarely do we implant a child with additional disabilities likely to interfere with their ability to participate in assessment, programming, or therapy programs designed to
* Corresponding author. Tel.: +1 213 353 7005; fax: +1 213 483 3716. E-mail address: [email protected] (M. Winter). 0531-5131/ D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2004.08.017
278
M. Winter et al. / International Congress Series 1273 (2004) 277–280
maximize linguistic benefit post-implant. However, as more children receive implants at or below 12 months of age, the number of implanted children with developmental or behavioral disabilities that cannot be assessed prior to implantation will also increase. Furthermore, as programming techniques that do not require the child to give a behavioral response become more refined, concerns about the child’s ability to participate in mapping may become less relevant. As a precursor to further study into the potential benefits of implanting such children, we looked at the outcomes in 10 children who showed evidence of developmental or behavioral delay or disorder prior to or following cochlear implantation in our program. 2. Subjects Subjects were grouped loosely into four diagnostic categories. Two children, both postmeningitis, demonstrated behaviors along the autism/PDD spectrum. Three children had been diagnosed with congenital cytomegalovirus (CMV), while another child began to show signs of a nonspecific neurologic disorder post-implant characterized by seizures and other neural abnormalities. The four remaining children were diagnosed with severe sensory integration disorders. Mean age at implantation was 3 years, 2 months (range: 1 year, 7 months to 4 years, 0 months), with only one child implanted as late as 4 years. All but the two children who were post-meningitis scored at or above age level on standard nonverbal cognitive measures. Nine of the 10 children were in oral educational programs at the time of implantation; one child was in a total communication (TC) program and received supplemental auditory habilitation therapy. 3. Methods Because the children were implanted over a range of years, not all of them received the same battery of speech perception tests. The tests performed most consistently across all subjects were the Ling Six Sound Test [1], the Early Speech Perception (ESP) test [2], and the Test of Auditory Comprehension (TAC) [3]. Results for the ESP and TAC for a group of 10 children without developmental delays or concerns were compared with those for the study children. The children comprising the comparison group were selected on the basis of similarity in age of implantation (mean=3 years, 0 months; range=1 year, 8 months to 3 years, 9 months) and education services to the study group. 4. Results 4.1. Ling Six Sound Test The Ling Six Sound Test (m, ah, oo, ee, sh, s) samples a child’s ability to detect and identify speech sounds representative of the speech frequency spectrum. The test was scored two ways: the number of sounds detected and the number identified, out of 30 presentations. In their best performance to date, all 10 study children achieved 100% detection. However, at a minimum of 2 years post-implant, only half of the children have been able to identify more than 2/3 of the sounds.
M. Winter et al. / International Congress Series 1273 (2004) 277–280
279
4.2. Early Speech Perception Test The ESP is a closed-set picture-pointing test designed to assess developing speech perception skills in young deaf children with limited vocabularies. Results place children in one of four speech perception categories: 1=detection/no pattern perception, 2=pattern perception, 3=some word identification, 4=consistent word identification. The standard version consists of word items known by most hearing-impaired children by the age of 6. The low-verbal version was designed to be administered to children as young as 2 years with very limited vocabularies [2]. At 1 year post-implant, eight of the study children were unable to demonstrate pattern perception ability on the low verbal version of the ESP (Fig. 1A). One child did achieve pattern perception (Category 2, low verbal), while another achieved consistent word identification (Category 4) on the standard version of the test. In contrast, all 10 children in the comparison group had achieved at least some word identification (Category 3) at 1 year post-implant, with half achieving consistent word identification (Category 4) (Fig. 1B). Moreover, eight of these normally developing children could be tested with the standard version of the ESP. At 2 years post-implant (not shown), four study children had achieved Category 2 (pattern perception). However, in their best performance to date (2–5 years post), only one child (Cmv 2) demonstrated further progress, achieving Category 3 (some word identification) by year 3 post-implantation. 4.3. Test of Auditory Comprehension The TAC is a closed-set test that assesses a hierarchy of auditory skills ranging from simple discrimination between linguistic versus nonlinguistic stimuli (Subtest 1) to recall of five details with competing messages (Subtest 10). At 2 years post-implant, four study children were unable to pass Subtest 1 (speech versus noisemakers) (Fig. 2A). Three children were able to pass Subtest 1, but were unable to pass Subtest 2 (speech versus laughing versus dog barking). One child was able to pass Subtest 2. At the same post-implant interval, all 10 children in the comparison group were able to pass Subtest 4 (core noun vocabulary) or better; the best performer was able to pass Subtest 7 (sequencing three events) (Fig. 2B).
Fig. 1. ESP category achieved at 1 year post-implant for 10 implanted children with developmental delays and/or behavioral disabilities (A) and 10 children with no known developmental delays or concerns (B). Data labels for individual children in group A correspond to secondary diagnoses as follows: Men=post-meningitis, Nsn= nonspecific neurologic disorder, Cmv=cytomegalovirus, Ssi=severe sensory integration issues. Scores obtained using standard version are designated by asterisk (*); the remainder were obtained using the low-verbal version.
280
M. Winter et al. / International Congress Series 1273 (2004) 277–280
Fig. 2. TAC subtest achieved at 2 years post-implant for study group (A) and comparison group (B).
4.4. Current educational placement Although nine of the children began in oral educational placements, at the most recent test interval (ranging across subjects from 2 to 5 years), most of the children did not make sufficient gains in oral language development to remain in oral programs. Two children could be classified as functional oral communicators, although the language achievement of one of them was well below age level. The child who was in a TC program at the time of implantation remained in that program; six other children had moved or planned to move in the next school session to total communication programs. The remaining subject still attended an oral program and received auditory verbal therapy by parental choice, even though the child had shown minimal growth in auditory skill development and showed no measurable growth of oral language skills, either receptive or expressive, on standardized testing. 5. Discussion As a retrospective study, these data are not conclusive, but are clearly cautionary. Children with developmental delays certainly may derive benefit from implantation even if they do not benefit linguistically in any measurable way. But since no child can afford to fall far behind in language development, particular concern about children with developmental delays is indicated as these children may have more difficulty acquiring language in any modality. More appropriate educational programs are needed for implanted children who do not progress well in oral language development; currently, the only realistic choices in many geographic areas may be between oral programs that do not support these children’s language needs and TC programs that lack auditory emphasis and do not support continued auditory growth. Further study is clearly needed to determine circumstances under which it is appropriate to implant children from special populations and how we can best substantiate and monitor any benefits, linguistic and otherwise, that the implant may provide. References [1] D. Ling, Foundations of Spoken Language for Hearing Impaired Children, The Alexander Graham Bell Association for the Deaf, Washington, DC, 1989. [2] J. Moog, A. Geers, Early Speech Perception Test for Profoundly Hearing-Impaired Children, Central Institute for the Deaf, St. Louis, MO, 1990. [3] J. Trammell, S. Owens, Test of Auditory Comprehension, Foreworks Publishing, North Hollywood, CA, 1977.
www.ics-elsevier.com
Performance of implanted children with developmental delays and/or behavioral disorders: retrospective analysis Margaret Winter*, Karen C. Johnson, Annie Vranesic Children’s Auditory Research and Evaluation (CARE) Center, House Ear Institute, 2100 W. Third St., Los Angeles, CA 90057, United States
Abstract. Deaf children with additional disabilities are receiving cochlear implants with increasing frequency. Although it has not been the routine policy of the House Ear Institute/House Ear Clinic team to implant children with developmental delays and/or behavioral disorders, a small number of our implanted children have shown evidence of such disabilities, either before or after implantation. Retrospective analysis of the post-implant performance and educational status of 10 of these children shows that most have made only minimal gains in functional oral communication ability, despite appropriate educational and therapy services. Although we believe that some children with developmental delays or disorders may benefit from implantation, these gains may not be tapped using our current metrics of post-implant performance. Furthermore, we have found that the educational programs available to many implanted children with additional needs do not adequately support both implant-facilitated language growth and the development of alternative forms of communication. D 2004 Elsevier B.V. All rights reserved. Keywords: Cochlear implants; Deaf children; Developmental delay; Behavioral disorder
1. Introduction The House Ear Institute/House Ear Clinic program has been slow to embrace the routine cochlear implantation of children with developmental and/or behavioral delays and disorders. Rarely do we implant a child with additional disabilities likely to interfere with their ability to participate in assessment, programming, or therapy programs designed to
* Corresponding author. Tel.: +1 213 353 7005; fax: +1 213 483 3716. E-mail address: [email protected] (M. Winter). 0531-5131/ D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2004.08.017
278
M. Winter et al. / International Congress Series 1273 (2004) 277–280
maximize linguistic benefit post-implant. However, as more children receive implants at or below 12 months of age, the number of implanted children with developmental or behavioral disabilities that cannot be assessed prior to implantation will also increase. Furthermore, as programming techniques that do not require the child to give a behavioral response become more refined, concerns about the child’s ability to participate in mapping may become less relevant. As a precursor to further study into the potential benefits of implanting such children, we looked at the outcomes in 10 children who showed evidence of developmental or behavioral delay or disorder prior to or following cochlear implantation in our program. 2. Subjects Subjects were grouped loosely into four diagnostic categories. Two children, both postmeningitis, demonstrated behaviors along the autism/PDD spectrum. Three children had been diagnosed with congenital cytomegalovirus (CMV), while another child began to show signs of a nonspecific neurologic disorder post-implant characterized by seizures and other neural abnormalities. The four remaining children were diagnosed with severe sensory integration disorders. Mean age at implantation was 3 years, 2 months (range: 1 year, 7 months to 4 years, 0 months), with only one child implanted as late as 4 years. All but the two children who were post-meningitis scored at or above age level on standard nonverbal cognitive measures. Nine of the 10 children were in oral educational programs at the time of implantation; one child was in a total communication (TC) program and received supplemental auditory habilitation therapy. 3. Methods Because the children were implanted over a range of years, not all of them received the same battery of speech perception tests. The tests performed most consistently across all subjects were the Ling Six Sound Test [1], the Early Speech Perception (ESP) test [2], and the Test of Auditory Comprehension (TAC) [3]. Results for the ESP and TAC for a group of 10 children without developmental delays or concerns were compared with those for the study children. The children comprising the comparison group were selected on the basis of similarity in age of implantation (mean=3 years, 0 months; range=1 year, 8 months to 3 years, 9 months) and education services to the study group. 4. Results 4.1. Ling Six Sound Test The Ling Six Sound Test (m, ah, oo, ee, sh, s) samples a child’s ability to detect and identify speech sounds representative of the speech frequency spectrum. The test was scored two ways: the number of sounds detected and the number identified, out of 30 presentations. In their best performance to date, all 10 study children achieved 100% detection. However, at a minimum of 2 years post-implant, only half of the children have been able to identify more than 2/3 of the sounds.
M. Winter et al. / International Congress Series 1273 (2004) 277–280
279
4.2. Early Speech Perception Test The ESP is a closed-set picture-pointing test designed to assess developing speech perception skills in young deaf children with limited vocabularies. Results place children in one of four speech perception categories: 1=detection/no pattern perception, 2=pattern perception, 3=some word identification, 4=consistent word identification. The standard version consists of word items known by most hearing-impaired children by the age of 6. The low-verbal version was designed to be administered to children as young as 2 years with very limited vocabularies [2]. At 1 year post-implant, eight of the study children were unable to demonstrate pattern perception ability on the low verbal version of the ESP (Fig. 1A). One child did achieve pattern perception (Category 2, low verbal), while another achieved consistent word identification (Category 4) on the standard version of the test. In contrast, all 10 children in the comparison group had achieved at least some word identification (Category 3) at 1 year post-implant, with half achieving consistent word identification (Category 4) (Fig. 1B). Moreover, eight of these normally developing children could be tested with the standard version of the ESP. At 2 years post-implant (not shown), four study children had achieved Category 2 (pattern perception). However, in their best performance to date (2–5 years post), only one child (Cmv 2) demonstrated further progress, achieving Category 3 (some word identification) by year 3 post-implantation. 4.3. Test of Auditory Comprehension The TAC is a closed-set test that assesses a hierarchy of auditory skills ranging from simple discrimination between linguistic versus nonlinguistic stimuli (Subtest 1) to recall of five details with competing messages (Subtest 10). At 2 years post-implant, four study children were unable to pass Subtest 1 (speech versus noisemakers) (Fig. 2A). Three children were able to pass Subtest 1, but were unable to pass Subtest 2 (speech versus laughing versus dog barking). One child was able to pass Subtest 2. At the same post-implant interval, all 10 children in the comparison group were able to pass Subtest 4 (core noun vocabulary) or better; the best performer was able to pass Subtest 7 (sequencing three events) (Fig. 2B).
Fig. 1. ESP category achieved at 1 year post-implant for 10 implanted children with developmental delays and/or behavioral disabilities (A) and 10 children with no known developmental delays or concerns (B). Data labels for individual children in group A correspond to secondary diagnoses as follows: Men=post-meningitis, Nsn= nonspecific neurologic disorder, Cmv=cytomegalovirus, Ssi=severe sensory integration issues. Scores obtained using standard version are designated by asterisk (*); the remainder were obtained using the low-verbal version.
280
M. Winter et al. / International Congress Series 1273 (2004) 277–280
Fig. 2. TAC subtest achieved at 2 years post-implant for study group (A) and comparison group (B).
4.4. Current educational placement Although nine of the children began in oral educational placements, at the most recent test interval (ranging across subjects from 2 to 5 years), most of the children did not make sufficient gains in oral language development to remain in oral programs. Two children could be classified as functional oral communicators, although the language achievement of one of them was well below age level. The child who was in a TC program at the time of implantation remained in that program; six other children had moved or planned to move in the next school session to total communication programs. The remaining subject still attended an oral program and received auditory verbal therapy by parental choice, even though the child had shown minimal growth in auditory skill development and showed no measurable growth of oral language skills, either receptive or expressive, on standardized testing. 5. Discussion As a retrospective study, these data are not conclusive, but are clearly cautionary. Children with developmental delays certainly may derive benefit from implantation even if they do not benefit linguistically in any measurable way. But since no child can afford to fall far behind in language development, particular concern about children with developmental delays is indicated as these children may have more difficulty acquiring language in any modality. More appropriate educational programs are needed for implanted children who do not progress well in oral language development; currently, the only realistic choices in many geographic areas may be between oral programs that do not support these children’s language needs and TC programs that lack auditory emphasis and do not support continued auditory growth. Further study is clearly needed to determine circumstances under which it is appropriate to implant children from special populations and how we can best substantiate and monitor any benefits, linguistic and otherwise, that the implant may provide. References [1] D. Ling, Foundations of Spoken Language for Hearing Impaired Children, The Alexander Graham Bell Association for the Deaf, Washington, DC, 1989. [2] J. Moog, A. Geers, Early Speech Perception Test for Profoundly Hearing-Impaired Children, Central Institute for the Deaf, St. Louis, MO, 1990. [3] J. Trammell, S. Owens, Test of Auditory Comprehension, Foreworks Publishing, North Hollywood, CA, 1977.