Word- and segment-level nasalance patterns in Greek-learning children with and without cochlear implants

Should All Deaf Children Learn Sign Language?

You have accessThe ASHA LeaderFeature1 Mar 2005Aural Habilitation Update: The Role of Speech Production Skills of Infants and Children With Hearing Loss Sheila R. Pratt Sheila R. Pratt Google Scholar More articles by this author https://doi.org/10.1044/leader.FTR2.10042005.8 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In It is well known that the development of speech is extremely limited without adequate auditory input and feedback. An obvious example is that hearing loss in infancy and early childhood usually affects all as pects of speech production unless there is early and consistent use of sensory aids as well as substantive sensorimotor and linguistic training. The speech development of infants and children with hearing loss hinges on their abilities to use audition not only to learn the sounds of their language, but also to use their articulators to produce those sounds and make use of auditory feedback to refine their speech over time. As such, the speech of children with prelingual hearing loss is particularly susceptible to delay and disorder, es pecially if the severity of the hearing loss is substantial and intervention is delayed or inadequate. Speech Development During the first six months of life (and possibly in utero) auditory perceptual learning is vital for acquiring oral language and speech, although the maturation timeline for the speech production in normal-hearing children is relatively lengthy. This protracted timeline may account for the long-term training and treatment needs of many children with hearing loss, even those identified and fitted early with sensory aids (Yoshinaga-Itano & Sedey, 2000). Young children with normal hearing typically begin babbling around 5–6 months of age and start verbal expression around 12 months of age. However, their speech production skills continue to be refined through the school-age years and well beyond when their basic phonological inventories have been established. For example, vowel space, voice-onset times, and vocal control adjust throughout early childhood (Assmann & Katz, 2000; Koenig, 2001; Lee, Pontamianos, & Naray anan, 1999). Furthermore, substantial acoustic variability is a hallmark of children’s speech production until late childhood. Although the research is somewhat mixed on the development of coarticulation, children appear to be less able than adults to coarticulate their speech gestures in a consistent manner, and as a consequence, their speech is less intelligible than that of adults (Katz, Kripke, & Tallal, 1991; Nittrouer, 1993). The refinement of auditory processing of speech has a similar developmental timeline. Child ren may apply different rules or weights to speech cues than adults, and these weights change throughout childhood (Nittrouer, 2003; Nit trouer, Crowther, & Miller, 1998). Their auditory processing of speech also appears to be more susceptible to acoustic and linguistic perturbations than is observed with adults. Children are more adversely affected than adults by background noise, reverberation, talker variability, re ductions in signal bandwidth, and the number of signal channels (Eisenberg et al., 2000; Ryalls & Pisoni, 1997; Kortekaas & Stelmachowicz, 2000). The Role of Audition in Speech Development and Production For mature speakers, audition acts as an error detector and a means of monitoring speaking conditions. It is considered to be slower than other forms of sensory information (i.e., proprioception) generated during speech, and therefore is likely limited to a feedback role (Perkell et al., 1997). Speakers use audition to determine if their articulators have produced sounds that are acoustically off-target. Audition also provides information for corrective adjustments, and as a consequence, is a contributor to the maintenance of speech integrity. Studies of frequency and spectrally shifted speech feedback have shown that adults rapidly adjust to minor acoustic perturbations with compensatory and/or matching strategies (Bauer & Larson, 2003; Houde & Jordan, 2002; Jones & Munhall, 2002, 2003). They appear to adjust their articulators so that their speech productions match their internal representations. In addition to acting as an error detector, hearing is used by mature speakers to determine how they should adjust their speech in various acoustic, linguistic, and social environments. For example, adults know when to speak slower, louder, softer, or more precisely in order to accommodate their listener or the environmental conditions (Perkell et al., 1997). In contrast, many young children are unable to adjust the clarity of their speech, even when explicitly directed to do so (Ide-Helvie et al., 2004). Audition also allows the development of articulatory organization by providing information about how to position, move, and coordinate the articulators for speech, movements that can differ from those associated with vegetative functions of the mechanisms (Moore & Ruark, 1996). For ex ample, infants use audition to learn how to shift from a vegetative breathing pattern to a pattern that can support speech. They learn how to position and move their tongues and to judge the acoustic consequences of those gestures. Coord ination of the larynx with the vocal tract and upper airway articulators is refined over years but requires an intact auditory system (Koenig, 2001; Tye-Murray, 1992). The lip and jaw movements associated with speech in infants and young children are highly variable but distinct from sucking, chewing, and smiling (Green et al., 2000; Green, Moore, & Reilly, 2002; Moore & Ruark, 1996). The implication is that although the same peripheral mechanisms are used across oral and respiratory functions, the differing goals require substantially distinct coordination and feedback efforts. The coordination needed to chew and swallow efficiently develops over early childhood but is largely independent of hearing, whereas the coordination required to move between vowel and consonant gestures, particularly in a coordinated and coarticulated manner, is strongly influenced by hearing (Baum & Waldstein, 1991; Guenther, 1995; Tye-Murray, 1992; Waldstein & Baum, 1991). Audition has a primary sensorimotor role in the development of speech, but it also is fundamental to infants and young children learning the sounds of their language. Furthermore, it helps them learn how specific speech events relate to their phonology, so that with development, young children become more able to use their hearing to inform them about the sequencing of speech gestures and the correctness of subsequent productions. Over time children learn to use audition to monitor ongoing speech, detect errors, and make corrective adjustments. Hearing Loss and Speech Production Hearing loss is common in the general population but its effects on speech production are most pronounced with individuals whose hearing loss is congenital or acquired in early childhood. Most adults who acquire their hearing losses later in life suffer little or no deterioration in intelligibility, likely because their residual hearing provides sufficient feedback since their mature speech production systems rely more on orosensory than auditory information to maintain proper control (Guenther, 1995; Goehl & Kaufman, 1984; Perkell et al., 1997). The speech differences that they do exhibit are subtle and usually imperceptible, even in cases of complete or nearly complete adventitious hearing loss. Nonetheless, some adventitiously deafened adults exhibit reduced speaking rate, and compromised articulatory and phonatory precision (Kishon-Rabin et al., 1999; Lane & Webster, 1991; Lane et al., 1995; Leder et al., 1987; Waldstein, 1990; Perkell et al., 1992). These speech differences are similar in nature, but not in severity, to those observed with prelingually deafened speakers. Most infants and young children with hearing loss demonstrate disordered phonation and articulation, as well as delays in the acquisition of sound categories. The entire speech production system can be affected, from respiratory support to the coarticulation of ongoing speech (Pratt & Tye-Murray, 1997). This is especially true if the hearing loss is identified late or after a period of protracted hearing loss. Furthermore, the overlap and interaction of disordered sound production and linguistic delay contribute to poor speech integrity and restricted speech development. Babbling generally does not appear before 12 months of age (Oller & Eilers, 1988; Oller et al., 1985) and canonical babbling has been observed as late as 31 months in this population (Lynch, Oller, & Steffens, 1989). Infants also produce fewer instances of canonical babble and include a more limited range of consonants in their babble (Stoel-Gammon, 1988; Stoel-Gammon & Otomo, 1986; Wallace, Menn, & Yoshinaga-Itano, 2000). However, later speech intelligibility is better predicted by the consonant inventory used in emerging spoken language during the second year of life than during babble (Obenchain, Menn, & Yoshinaga-Itano, 2000). The phonetic repertoires of infants with severe-to-profound hearing loss often are restricted when compared to their normal-hearing peers, although there is abundant individual variability (Lach, Ling, Ling & Ship, 1970; Stoel-Gammon & Otomo, 1986; Wallace et al., 2000; Yoshinaga-Itano & Sedey, 2000). The early speech inventories of infants with severe-to-profound hearing loss predominately consist of motorically easy sounds such as vowels and bilabial consonants. The sounds of their inventories also contain more low frequency information, which is more audible. For example, the babbling of infants with hearing loss often has a high concentration of nasals and glides, which include low-frequency continuant cues (Stoel-Gammon & Otomo, 1986). Without early intervention and appropriate fitting of sensory aids the speech-sound inventories of many children with hearing loss usually do not attain full maturity. Yoshinaga-Itano and Sedey (2000) found that children with moderate-to-severe hearing losses did not reach an age-appropriate complement of vowel and consonant sounds until about 4 and 5 years respectively, and many children with profound hearing loss had restricted inventories even at 5 years of age. Children with profound hearing loss often reach an early plateau in their speech skill development. For instance, the speech characteristics of many children with severe-to-profound hearing loss demonstrate little improvement in sound inventory and intelligibility after 8 years of age, even with the initiation of extensive training (Hudgins & Number, 1942, McGarr, 1987; Smith, 1975). Such results imply that, like auditory and language interventions, speech production therapy should be an important component of early intervention, and that the common practice of delaying speech training in children with hearing loss until they have functional language is developmentally untenable if the goal is for them to be oral communicators. In addition to the relationship between age-of-onset and speech impairment severity, there also is a moderately positive relationship between the severity of hearing loss and the extent of the associated speech difficulties (Boothroyd, 1969; Levitt, 1987; Smith, 1975). For example, children with mild-to-moderate hearing loss, particularly if well aided, tend to exhibit speech differences that are mild (Elfenbein, Hardin-Jones, & Davis, 1994; Oller & Kelly, 1974; West & Weber, 1973). Elfenbein and colleagues found that children with mild-to-moderate hearing loss exhibit good intelligibility but had higher than normal rates of affricate and fricative substitutions. Mild hoarseness and resonance problems also are present in 20% to 30% of this group of children. Moreover, they tend to have increased rates of voicing irregularities, difficulties with /r/ production, and omissions of back and word-final consonants. Early studies of children with profound prelingual hearing loss showed that most rarely acquired speech skills sufficient to interact easily using spoken language. On average, less than 20% of their words were intelligible to listeners who were not familiar with their speech (Hidgins & Numbers 1942; Markides, 1970; Smith, 1975). Smith (1975) evaluated 40 children with varying levels of hearing loss and, on average, only 18.7% (0% to 76%) of their words could be identified by inexperienced listeners. As expected, overall intelligibility was inversely related to the frequency of segmental and suprasegmental errors. However, with early identification of hearing loss and early intervention (i.e., fitting of sensory devices, behavioral training, and parent counseling), the numbers of children with severe-to-profound hearing loss and intelligible speech has increased (Uchanski & Geers, 2003). Many more children are developing sufficient speech perception to support development of speech production and oral language, but these advances may have added to the overall heterogeneity of the population (Higgins et al., 2003). Other factors contribute to the diversity of speech production skills observed with these children. For instance, cognitive skill (particularly nonverbal intelligence) has been found to be an important predictor of functional speech and oral language in children with hearing loss (Geers et al., 2002; Tobey et al., 2003). Auditory experience in infancy and early childhood, even of limited duration, positively influences the speech production skills of children who have severe-to-profound hearing loss (Geers, 2004). The use of sensory aids has a substantial impact on speech outcomes, but somewhat surprisingly, the age at which infants and young children are fitted with cochlear implants has not surfaced in studies of speech production as a significant predictor of later speech intelligibility (Geers et al., 2002; Tobey et al., 2003). Early implantation (less than 2 years) is, however, related to more normal oral communication development as a whole (both speech and oral language) (Geers, 2004). It may be that the age of implantation is not easily separated from other influences of intervention, like the orientation of the habilitation program and parent involvement, which relate strongly to children being auditory perceptual learners and users of auditory feedback. Another consideration is that many early-implanted children may be implanted too late to observe a clear impact on speech production. The critical ages at which hearing aids should be fitted has not been investigated, but like cochlear implants, it is assumed that earlier is better. The oromotor integrity and language skills are additional factors that often are neglected in studies of speech development in children with hearing loss. A substantial number of infants and children with hearing loss present with secondary handicapping conditions, such as neurological disorders. When these neurological disorders include the speech mechanism, the development of functional speech is difficult even if audition is optimized. As such, is it not unusual for a child with hearing loss to have a coexisting dysarthria along with the speech impairment secondary to the hearing loss. A subset of children with hearing loss also may have an apraxia of speech, but separating the impact of hearing loss from an apraxia of speech is difficult because the associated speech characteristics overlap (McNeil, Robin & Schmidt, 1997). Language disorders also are commonly observed in children with hearing loss, and are frequently evidenced in phonological disorder and lexical delay. As a result, extricating the sensorimotor impact of hearing loss on speech production from the influences of language disorder in individual children is not always straightforward (Peng et al., 2004). Habilitation: Sensory Aids and Treatment Most speech training approaches are dependent on optimizing the use of residual hearing although some approaches use other modalities (Pratt, Heintzelman, & Deming, 1993; Pratt & Tye-Murray, 1997). Correspondingly, it is generally believed that speech is learned most easily if infants and children learn and monitor their speech through their auditory systems. Therefore, the proper and early fitting, and consistent use of sensory aids, along with auditory and language training are important components of speech production training. In support of this auditory-based approach is the relationship between the severity of prelingual hearing loss and the extent of speech delay/disorder found in children (Boothroyd, 1969; Levitt, 1987; Smith, 1975), as well as any history of previous hearing (Geers, 2004). The relationship between audiometric configuration and speech intelligibility also argues for the importance of audition if the goal for a child is oral communication (Levitt, 1987; Osberger, Maso, & Sam, 1993). There is a growing literature supporting the positive impact of cochlear implants on speech development, as well as the role that auditory-oral-based training programs play in communication outcomes of children fitted with cochlear implants (Geers et al., 2002; Tobey et al., 2003). There is, however, limited efficacy data for children with less severe hearing loss who are typically fitted with hearing aids. The lack of research in this area is glaring because wearable electroacoustic hearing aids have been available for more than 50 years (Lybarger, 1988) and are a fundamental component of treatment approaches for most children with hearing loss. Furthermore, more infants and children are fitted with hearing aids than cochlear implants. Preliminary data reported by Stemachowicz and her colleagues (2004) on three infants fitted early with hearing aids suggested delays in sound category acquisition consistent with patterns previously reported in the literature. Sound inventories were impoverished, consonants were more affected than vowels, and sound containing high-frequency cues were particularly limited. Additional data by Pittman and colleagues (2003) observed that the amplitude of high-frequency speech cues directed to and produced by children wearing hearing aids may not be sufficient, although they did not connect their results directly to speech production outcomes. Pratt, Grayhack, Palmer, and Sabo (2003) found that differences in hearing aid configuration could alter vowel spacing of children even though the children in their study had intelligible speech, and the speech tokens measured were limited to acceptable productions. Their data indicated that hearing aids could alter the speech of children, but provided little information about the impact that hearing aids may have on speech development. Given the paucity of data-as well as the expansion of universal infant hearing screening programs-it is critical that more research be done in this area. Increasing numbers of infants with hearing loss will be identified shortly after birth and, if we are to effectively treat them, more should be known about the impact that hearing aids and other sensory aids have on speech and auditory system development. Aural Habilitation References Assmann P. F., & Katz W. F. (2000). Time-varying spectral change in the vowels of children and adults.Journal of the Acoustic Society of America, 108, 1856–1866. CrossrefGoogle Scholar Baum S., & Waldstein R. (1991). Perseveratory coarticulation in the speech of profoundly hearing-impaired and normally hearing children.Journal of Speech and Hearing Research, 34, 1286–1292. LinkGoogle Scholar Bauer J. J., & Larson C. R. (2003). Audio-vocal responses to repetitive pitch-shift stimulation during a sustained vocalization: Improvements in methodology for the pitch-shifting technique.Journal of the Acoustical Society of America, 114, 1048–1054. CrossrefGoogle Scholar Boothroyd A. (1969). Distribution of hearing levels in the student population of the Clarke School for the Deaf. Northampton, MA: Clarke School for the Deaf. Google Scholar Elfenbein J., Hardin-Jones M., & Davis J. (1994). Oral communication skills of children who are hard of hearing.Journal of Speech and Hearing Research, 37, 216–226. LinkGoogle Scholar Eisenberg L., Shannon R., Martinez A. S., & Wygonski J. (2000). Speech recognition with reduced spectral cues as a function of age.Journal of the Acoustical Society of America, 107, 2704–2710. CrossrefGoogle Scholar Geers A., Brenner C., Nicholas J., Uchanski R., Tye-Murray N., & Tobey E. (2002). Rehabilitation factors contributing to implant benefit in children.Annals of Otology, Rhinology, and Laryngology—Supplement, 189, 127–130. CrossrefGoogle Scholar Goehl H., & Kaufman D. (1984). the effects of adventitious include disordered of Speech and Hearing LinkGoogle Scholar J. R., Moore C. A., M., & R. W. (2000). The development of speech and jaw of & Hearing Research, LinkGoogle Scholar J. R., Moore C. A., & J. (2002). The development of jaw and lip control for of and Hearing Research, LinkGoogle Scholar F. Speech sound coarticulation, and effects in a of speech CrossrefGoogle Scholar E. A., A. & (2003). in children’s speech and after cochlear and CrossrefGoogle Scholar Houde J. F., & of speech and of and Hearing Research, LinkGoogle Scholar C., & Numbers F. An of the intelligibility of speech of the Google Scholar D. L., W. A., C., A. J., & used to speech clarity by normal-hearing children.Journal of the Acoustical Society of America, CrossrefGoogle Scholar Jones J. A., & (2002). The role of auditory feedback during Studies of of CrossrefGoogle Scholar Jones J. A., & (2003). to produce speech with an vocal The role of auditory of the Acoustical Society of America, CrossrefGoogle Scholar Katz W. F., C., & P. (1991). coarticulation in the speech of adults and young perceptual and of Speech and Hearing Research, 34, LinkGoogle Scholar L., R., & The of hearing on speech production of deafened adults with cochlear of the Acoustical Society of America, CrossrefGoogle Scholar characteristics of in children’s and of developmental of Speech and Hearing Research, LinkGoogle Scholar Kortekaas R., & P. (2000). effects on children’s perception of the Acoustical auditory and clarity of and Hearing Research, LinkGoogle Scholar R., Ling Ling L., & Early speech development in of the Google Scholar Lane H., & J. W. (1991). Speech deterioration in deafened adults.Journal of the Acoustical Society of America, CrossrefGoogle Scholar Lane H., J., M., M., & Perkell J. in the speech of cochlear implant An of of the Acoustical Society of America, CrossrefGoogle Scholar Leder S., J., J. C., C., & F. of adventitiously cochlear implant of the Acoustical Society of CrossrefGoogle Scholar S., A., & Acoustic of children’s of and spectral of the Acoustical Society of America, CrossrefGoogle Scholar the speech and language H., N., & D. Development of language and communication skills of hearing-impaired children. ASHA Google Scholar A R. of hearing aid MA: Google Scholar M., Oller & Development of in a child with congenital of The of CrossrefGoogle Scholar skills of hearing-impaired children in for the H., N., & D. Development of language & communication in hearing children. ASHA Google Scholar R., Robin D. A., & R. A. of and of sensorimotor speech disorders Google Scholar A. The speech of and hearing children with to factors of of CrossrefGoogle Scholar Moore C. A., & J. speech from earlier oral of Speech and Hearing Research, LinkGoogle Scholar (2002). to fricative perception and how it the of the Acoustical Society of America, CrossrefGoogle Scholar S., C. S., & E. The of acoustic in the perception of by children and & CrossrefGoogle Scholar L., & Yoshinaga-Itano C. (2000). speech development at months in children with hearing loss be predicted from information available in the second year of Google Scholar Oller R., & A. of a A with normal of Speech and Hearing Research, LinkGoogle Scholar Oller & C. of a of Speech and Hearing LinkGoogle Scholar J., M., & Speech intelligibility of children with cochlear implants, aids, or hearing of Speech and Hearing Research, LinkGoogle Scholar S., A. L., H., & production and language skills in children with cochlear of and CrossrefGoogle Scholar Perkell J., Lane H., M., & J. Speech of cochlear implant A study of vowel of the Acoustical Society of America, CrossrefGoogle Scholar Perkell J. S., L., Lane H., F. H., R., J., & P. Speech Acoustic auditory feedback and internal CrossrefGoogle Scholar Pittman A. L., Stemachowicz P. D. & (2003). characteristics of speech at the for in children.Journal of and Hearing Research, LinkGoogle Scholar Pratt R., A. & E. The efficacy of using the to treat young children with hearing of Speech and Hearing Research, LinkGoogle Scholar Pratt R., & Tye-Murray A. Speech impairment secondary to hearing of sensorimotor speech disorders Google Scholar Smith C. hearing and speech production in the of Speech and Hearing Research, LinkGoogle Scholar P. Pittman A. L., M., D. & P. The importance of high-frequency in the speech and language development of children with hearing of and CrossrefGoogle Scholar Stoel-Gammon C. of hearing-impaired & normally hearing A of of Speech and Hearing LinkGoogle Scholar Stoel-Gammon C., & Babbling development of hearing-impaired and normally hearing of Speech and Hearing LinkGoogle Scholar Tobey E. A., Geers A. Brenner C., & (2003). associated with development of speech production skills in children implanted by age and CrossrefGoogle Scholar Uchanski R. M., & Geers A. E. (2003). Acoustic characteristics of the speech of young cochlear implant A with normal-hearing and CrossrefGoogle Scholar Waldstein R. of on speech for the role of auditory of the Acoustical Society of America, CrossrefGoogle Scholar Waldstein R., & Baum (1991). coarticulation in the speech of profoundly hearing-impaired and normally hearing children.Journal of Speech and Hearing Research, 34, LinkGoogle Scholar Wallace L., & Yoshinaga-Itano C. (2000). babble the to speech for all A study of children who are or hard of Google Scholar Sheila R. Pratt, is in the of & at the of her at With With Additional to in Mar &

Lessons from LOCHI.

Technology and Early Childhood Deafness

Auditory Brain Development in Children with Hearing Loss – Part Two

THE ARGUMENT FOR FITTING BIMODALLY If you see a child tomorrow with a hearing loss in both ears, will you recommend one hearing aid or two? The obvious answer is two. You would have a hard time finding a dispensing professional today who does not agree that the benefits of bilateral hearing aid fitting make it the standard of care for those with binaural hearing loss. While the benefits of binaural hearing and the advantage of bilateral fitting are beyond the scope of this article (e.g., see Litovsky et al.,1 Kochkin2), these facts are undisputed in hearing healthcare circles. The industry's confidence in bilateral hearing aids is supported by current trends in fitting. In 1980 only 27% of hearing aid fittings were bilateral.3 Today, it is an amazing 86% for those with binaural hearing loss.4 So, what is bimodal fitting and why should dispensing professionals care? Bimodal fitting means different stimuli are presented to each ear. For the purposes of this paper, it means a cochlear implant in one ear and a hearing aid in the other. But, you may ask, don't cochlear implant audiologists take care of that? The answer is no, at least not usually. Personal experience (first author), communication with cochlear implant audiologists, and the literature5 suggest that most hearing aids in bimodal devices are fitted outside the cochlear implant center. Thus, if you have a patient who receives a cochlear implant in one ear, you will most likely be the one responsible for the continuing care of the hearing aid in the contralateral ear. It is in the best interests of both your patient and you to know how to optimize the hearing aid fitting for the best bimodal performance. If you fit hearing aids on children, the question is not if you will be responsible for managing a child with bimodal devices, but rather when. The number of unilateral cochlear implant recipients who continue to use contralateral hearing aids is clearly increasing (Figure 1). The conventional wisdom that cochlear implants and hearing aids should not be used simultaneously is archaic,6,7as we will show in this paper.Figure 1: Percentage of unilateral cochlear implant users choosing to wear a hearing aid in the contralateral ear. Sources: Tyler et al.,8 Cowan and Chin-Lenn9.BIMODAL DEVICE USE IN CI WEARERS Significant advances over the years in cochlear implant technology, speech-coding strategies, and surgical techniques have resulted in substantial improvements in the auditory-only speech-understanding abilities of cochlear implant recipients.10 As a result, the candidacy criteria approved for cochlear implantation in the United States has progressively expanded. When Cochlear Corporation, Ltd., introduced the original Nucleus® cochlear implant in 1985, the only candidates approved by the Food and Drug Administration were adults with profound bilateral sensorineural hearing loss of post-linguistic origin who had 0% open-set speech recognition using hearing aids. Now, under the FDA criteria approved in 2005, candidates can be adults or children aged 12 months and older, and can have either pre- or post-lingual onset of hearing loss. Although mid- and high-frequency hearing must still be profound (hearing thresholds >90 dB HL), low-frequency hearing loss can be moderate for adults (hearing thresholds >40 dB HL) and severe for children over age 2 (hearing thresholds >70 dB HL). Further, best-aided pre-operative speech-recognition criteria have been raised from 0% to <60%. Figure 2 shows the current criteria for each age group.Figure 2: Current FDA-approved audiometric and speech-recognition criteria for cochlear implantation with the Nucleus device, by age group. (For children, the open-set word-recognition test recommended is the Lexical Neighborhood Test [LNT] or Multisyllabic Lexical Neighborhood Test [MLNT], which are available from www.auditec.com.)For persons with bilaterally profound sensorineural deafness (the purple-shaded area in Figure 2), cochlear implants are clearly the intervention of choice because many obtain little or no benefit from hearing aids. However, for children aged 2 years and up and for adults, there is a range of low-frequency thresholds (the green and yellow areas, respectively) that fall within the approved audiometric range for cochlear implants. Hearing aids often fail to provide adequate performance for these patients,11but a unilateral cochlear implant alone does not provide all the known benefits that arise from listening with two ears rather than one. Binaural benefits from perception of interaural differences in time and intensity are well known to improve speech-recognition performance, particularly in background noise, due to a combination of head shadow, binaural redundancy, and binaural squelch effects (e.g., see Byrne, 198112 for a review). Further, bilateral inputs provide the potential for good localization ability. Finally, a strong argument can be made for bilateral stimulation, especially in children, in light of the impact of auditory deprivation on perception. When a hearing-impaired ear remains unaided, speech-recognition ability in that ear significantly deteriorates over time,13,14 and there appears to be a limited window of opportunity for auditory system stimulation if the patient is to achieve maximal binaural functioning.15 Bilateral implantation is not for everyone. For example, there might be significant usable hearing in one ear. There may be insurance reimbursement or financial barriers. Parents may worry about surgery or preserving one ear for possible future technology or treatments. These concerns may or may not be well-founded. Insurance reimbursement is not the obstacle it once was. Cochlear brand implants are designed to be “backward compatible” so future advances can be applied to implants done today. Cotanche reported that treatment, e.g., hair cell regeneration, may be 20 years or more away.16 However, unilateral versus bilateral implantation in children is ultimately the parents' choice and their wishes must be respected. The less expensive, non-invasive fitting of a hearing aid on the ear contralateral to a cochlear implant allows preservation of hearing in that ear and may provide the benefits of binaural stimulation. SUMMARY OF THE LITERATURE The bimodal fitting approach was first reported in the literature in the early 1990s (e.g., Shallop et al., 199217). Concerns were initially expressed that patients might be unable to combine the two very different sound sources for central processing. Fortunately, this has not proven to be the case. In fact, some researchers have argued that bimodal stimulation may provide “complementary” cues for processing of signals that may be advantageous to speech perception.18 Specifically, the lower frequencies provided by the hearing aid can provide information about the fundamental frequencies of a talker's voice and vowel information, while the mid- and high-frequency information from the cochlear implant can provide information needed on manner and place of articulation of consonants. It has also been suggested that localization ability, sound quality, and music perception may be enhanced by bimodal devices compared with bilateral cochlear implants.19,20 Studies have reported significant speech-recognition improvements for bimodal listening compared to either the patients' pre-operative bilateral hearing aid use or their post-operative use of the hearing aid or cochlear implant alone. This has been shown in adults17,21–23 and in children.24–26 For example, in a study by Luntz et al.,26 12 subjects (3 post-lingually impaired adults and 9 pre-lingually impaired adults and children aged 7 and older) were tested on sentences in noise after 7 to 12 months of using bimodal devices. Both speech (at 55 dB HL) and noise (at 45 dB HL) were presented from a frontal loudspeaker. Average speech-recognition scores were only 12.9% for the hearing aid alone and 60.7% for the cochlear implant alone, but bimodal listening produced an average score of 75.6% correct. Localization abilities have been shown to improve with bimodal devices relative to use of either device alone for some, although not all, adult2728 and pediatric1,24 patients. Many users of bimodal devices have also reported higher levels of satisfaction and perceived benefit than with hearing aids worn pre-implantation, although cosmetic and handling concerns of using the two devices have sometimes been expressed,29 emphasizing the need for sufficient counseling and training. It is also important to consider that children may need more time to learn to use bimodal cues.25 There is debate over the relative effectiveness of bilateral cochlear implants versus bimodal devices. Overall, however, the published literature on bimodal devices has been quite positive (e.g. see Ching et al. for a review18). A judicious approach would be to fit a hearing aid contralaterally to the implant on patients who show sufficient benefit from the hearing aid and are able to use the binaural cues provided. FACTORS IN FITTING THE HEARING AID Certain aspects of the fitting need to be considered and possibly modified for optimal use of bimodal devices. Dispensing professionals who follow proven, evidence-based protocols for hearing aid fitting, however, will require minimal adaptation of their normal procedure. The American Academy of Audiology has published a Pediatric Amplification Protocol and all professionals dispensing hearing aids to children should be familiar with it.30 Optimization of the hearing aid in bimodal fittings essentially requires three steps. First, the cochlear implant map must be stable. You will need to communicate with the cochlear implant audiologist to know when this has been accomplished. Second, a frequency response should be selected for the hearing aid that will provide the best speech intelligibility. This is established by starting with a hearing aid that has been fitted and verified using a prescriptive formula. While the first author has had success using NAL-NL1,31 and Ching recommended it as an optimal starting point,32 those who are proficient with DSL[i/o]33 or another validated prescriptive approach should not be discouraged from using it as the starting point. From the initial prescription, two alternate frequency responses should be programmed into the hearing aid and adjusted for equal loudness. This is easy in multiple-memory digital hearing aids. As the limits of the hearing aid permit, program one should be the selected prescriptive formula frequency response. Program two should have 6-dB per octave less amplification in the low frequencies (-6 dB at 1000 Hz, -12 dB at 500 Hz, and -18 dB at 250 Hz). Program three should have 6-dB per octave more amplification in the low frequencies (+6 dB at 1000 Hz, +12 dB at 500 Hz, and +18 dB at 250 Hz). Once the programs are established, the child should listen to connected discourse while the audiologist switches between programs to determine which one provides the clearest speech. This can be done by playing a recorded story or watching a child-friendly video. The cochlear implant should be turned off during this frequency response selection process. Ching reported that this procedure is appropriate for children as young as 6 years.32 For younger children, the professional may choose to default to the prescriptive response. Finally, the third step in the fitting protocol is to match overall loudness between the hearing aid and cochlear implant. Both the implant and the aid are turned on and the child is asked to report if the hearing aid is louder or softer than the cochlear implant. The aid is then adjusted accordingly. This can also be done while the child listens to a recorded story or watches a video. A chart like that in Figure 3 can be helpful for this task. Some children might experience loudness discomfort from amplification. If so, Ullauri et al. suggest starting with a lower volume setting on the hearing aid and raising it over time as acclimatization occurs until the level of balanced loudness is achieved.34Figure 3: Loudness balancing scale. Source: Cochlear in-house material.A flow chart for fitting the hearing aid in bimodal devices is shown in Figure 4. This recommended protocol has been validated in children and found to provide good binaural benefits.24 For the reader wishing more in-depth training, a tutorial is available at www.cochlearcollege.com. Ching et al. have also published excellent articles on fitting and adjusting the hearing aid for children wearing bimodal devices.2,35Figure 4: Optimizing the hearing aid in bimodal fitting. Source: Cochlear in-house material.CONCLUSIONS The use of bimodal devices is the recommended treatment option for children who meet cochlear implant candidacy but who either have some usable hearing in one ear or for other reasons get only one implant. Bimodal devices can be a successful alternative to bilateral hearing aids or to one cochlear implant alone. It is important to remember these three vital rules: (1) Work with the implant center to make sure the implant map is stable. (2) Fit the hearing aid frequency response for maximal speech intelligibility. (3) Balance the loudness with the cochlear implant and hearing aid. Bimodal fitting can provide optimal use of the different, but potentially complementary, bilateral cues provided by the acoustic amplifier and the electric stimulation from the implant.

Improvements in digital amplification, cochlear implants, and other innovations have extended the potential for improving hearing function; yet, there remains a need for further hearing improvement in challenging listening situations, such as when trying to understand speech in noise or when listening to music. Here, we review evidence from animal and human models of plasticity in the brain's ability to process speech and other meaningful stimuli. We considered studies targeting populations of younger through older adults, emphasizing studies that have employed randomized controlled designs and have made connections between neural and behavioral changes. Overall results indicate that the brain remains malleable through older adulthood, provided that treatment algorithms have been modified to allow for changes in learning with age. Improvements in speech-in-noise perception and cognition function accompany neural changes in auditory processing. The training-related improvements noted across studies support the need to consider auditory training strategies in the management of individuals who express concerns about hearing in difficult listening situations. Given evidence from studies engaging the brain's reward centers, future research should consider how these centers can be naturally activated during training.

Assessing Listening Skills in Children with Cochlear Implants: Guidance for Speech-Language Pathologists

A cochlear implant (CI) is a hearing device introduced in the 1980s for profoundly deaf subjects who gained little or no benefit from powerful hearing aids. This device comprises an electrode array inserted in the cochlea, connected to an internal receiver, and an externally worn speech processor. The CI transforms acoustic signals into electrical currents which directly stimulate the auditory nerve. Since the early 1990s, cochlear implantation in children has been developing rapidly. Although it is still difficult to predict how a child will perform with a cochlear implant, the success of cochlear implantation can no longer be denied. In this paper, some recent papers and reports, and the results of the various Nijmegen cochlear implant studies, are reviewed. Issues about selection, examinations, surgery and the outcome are discussed. Overall, our results were comparable with those of other authors. It can be concluded that cochlear implantation is an effective treatment for postlingually deaf as well as prelingually (congenital or acquired) deaf children with profound bilateral sensorineural deafness.

Music to the Impaired or Implanted Ear

You have accessThe ASHA LeaderFeature1 Mar 2002The Psychology of Hearing Loss Mary Kaland and Kate Salvatore Mary Kaland Google Scholar and Kate Salvatore Google Scholar https://doi.org/10.1044/leader.FTR1.07052002.4 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In The experience of hearing loss is different for everyone. Speech-language pathologists and audiologists need to have a good grasp of both the physical—and psychological—realities of hearing loss. Hearing loss makes communication with the outside world difficult, and an individual's personality affects adaptation of hearing loss. A psychologist and psychiatrist, both hard-of-hearing themselves, bring an inside view to some of the potential psychological effects of hearing loss and the ways that clinicians can address them. No two people have the same reaction to life circumstances. Hearing loss can induce observable psychological effects at various points in development. The potential psychological effects of hearing loss are different for children and adults, and an individual's personality affects adaptation to hearing loss and cochlear implants. In general, hearing loss makes interaction with the outside world difficult. Having a hearing loss has been described as an invisible handicap, especially in the social realm. In fact, Helen Keller once said that deafness cuts one off from people, whereas blindness cuts one off from things. Hearing Loss in Children Hearing loss is challenging at any age, but it poses unique issues for the young child. Having a hearing loss does not mean a child will develop psychological problems, just as a child from a family of divorce may or may not have emotional difficulties. The stressor (hearing loss, divorce) is superimposed on pre-morbid personality (coping skills) as well as biological predispositions. It is a combination of psychological, biological, and social factors that make a child more at risk than the general population. Some of the more commonly noted secondary aspects of hearing loss include communication and behavioral problems, self-esteem and image problems, and depression and introversion. Undiagnosed or misdiagnosed hearing loss can result in problems as the child may know something is not quite right but is not getting the proper professional attention. When a hearing loss—even a mild one—is correctly diagnosed, the child knows the truth about what is wrong, as opposed to thinking she is "crazy" or "stupid." Though less common today, children may be misdiagnosed as attention- or emotionally disordered, which can lead to many secondary self-esteem issues. When misdiagnosis occurs, the problem becomes twofold—the child receives an inaccurate and usually negative label, and their actual problem goes untreated for a long period of time. To some extent, communication issues are universal among people with hearing loss. When a child has difficulty interacting in a spontaneous way, a whole host of secondary problems can arise, and any or all of these issues can develop into more serious problems. These include learning difficulties, social isolation, and depression. Normal interactions require tremendous attention for the child with hearing loss. Listening becomes a multi-sensory task, involving a much greater level of visual and general attention than it does for those with normal hearing. While the child may communicate effectively, it requires a great deal of energy to do so. One of the most typical symptoms that motivates individuals with hearing loss to begin psychotherapy is fatigue, which can exacerbate depression. Increased incidences of behavioral problems are often cited in the literature on children who are deaf or hard-of-hearing. Behavioral problems in children such as hyperactivity or aggression can be the outward expression of internal difficulties—such as depression, anxiety, and learning disorders— and should be investigated. Behavioral problems are often best dealt with by school or mental health professionals with experience in these areas. When treating children with behavioral problems, clinicians must set limits, speak simply and clearly, avoid overly stimulating or distracting environments, and involve parents more than usual. Scheduling appointments at optimum times of day (based on parental knowledge of when their child is usually at their best) is also useful. In addition, children rarely perceive being different as a virtue. Children with any unique qualities may develop a negative self-image as a result. This is often evident in children with a variety of traits that come to characterize them, such as being overweight and wearing glasses. One personality trait often associated with hearing loss is introversion—the terms shy, quiet, and sensitive often refer to this. The general theory is that the child with hearing loss is more inner-focused as a result of reduced stimulation from the outside world. They may withdraw from peer interactions due to this inner focus, the extra effort demanded in communicating, or simply due to the alienating feeling of "being different." As a result, parents must apply extra effort to helping their child with hearing loss participate with peers and in social groups. Self-expression is difficult for all children, and this is greatly compounded by hearing loss. Parents and professionals must be extra-sensitive to children with hearing loss, as they are not always able to articulate their needs and feelings. They must be aware of potential problems and assist the child with hearing loss in becoming more comfortable with self-expression. Children with hearing loss need to be in an environment that welcomes questions and feelings, and while parents may not always have the answers, they should be at ease and curious about the questions. Clinicians can ask children who have hearing loss questions in the course of their work ("How do you feel about your new hearing aid" or "What do you think about your new hearing aid?") in an unobtrusive and casual manner and watch the child's response. Be careful about leading questions. "How do you like your new hearing aid " may indicate to the child that he is supposed to like it, which does not promote honesty if the child actually does not like it. All children should be taught that they have strengths and weaknesses and be encouraged to explore who they are and pursue the things they like and do well. It is the difficult chore of the parents of children with hearing loss to continually explore and question whether behaviors observed are a normal manifestation of the child's personality or a response to some form of distress caused by the hearing loss. Parents must find the delicate balance between overanalyzing every behavior and not paying enough attention to their child's actions. Finally, parents need to develop their own support systems to help them deal with their feelings. Hearing Loss in Adults Hearing loss in adulthood is a somewhat different psychological picture. A distinction can be made between psychological symptoms of early- and late-onset hearing loss in adults, although individuals in both groups commonly report anger, denial, isolation, social withdrawal, fatigue, and depression. Adults with early-onset hearing loss may have grown up dealing with some of the above problems. Clinical psychological knowledge tells us that all children bring manifestations of their childhood difficulties into adulthood. Some of these difficulties will continue to be problematic, and some will not. For instance, the child with hearing loss who was isolated and had poor self-esteem may be an isolated adult who underachieves. Adults must be understood as the totality of their developmental experiences, and hearing loss and its consequences are a part of that whole. Clinicians need to be curious about how clients feel about their hearing loss, how it was managed and discussed in their family, and how they feel it affects their choices in adulthood. Adults who have early-onset hearing loss often report that, while there were negative aspects of their hearing loss, they have come to incorporate the hearing loss into their personalities—it is part of who they are and of their identity. As a result, they have developed ways to cope with and manage the hearing loss in their daily lives. The situation is very different for late-deafened adults. These individuals have developed a personality that does not incorporate hearing loss. They have jobs, families, and personalities and relate to those aspects of their lives as fixed. When hearing loss occurs, it is a very disorienting experience. Rapid losses are more disorienting than gradual losses. Late-deafened adults often report that their hearing loss robs them of an understanding of their identity and often initiates an identity crisis. They may manifest a "reactive" depression and/or anxiety in response to a typically external situation. Late-deafened adults will often mourn the loss of their hearing as they go through Kubler-Ross' five stages of grief—denial and isolation, anger, bargaining, depression, and acceptance (see references). Professionals interacting with late-deafened adults should try to get a general sense of which stages the client is in. Denial, isolation, and anger are readily observable by clinicians. A newly diagnosed adult may mourn the loss by becoming withdrawn and refusing amplification. Family members and audiologists are the greatest help in this early stage. Patients often need to be taught new ways to interact in the world to increase their involvement. Bargaining frequently takes the form of comparing ("I can't really hear anymore, but at least my health is good") or devaluing ("Who cares if I cannot hear—I never really liked music"). Depression can manifest itself as tearfulness, slowed responses, or even changes in weight or sleeping patterns. If previously dapper men begin showing up for appointments unshaven or women come without makeup and with sloppy hair, they may be depressed. Professionals can note such things in an unobtrusive way ("How are you feeling this week?") and even talk with family members if they come with the client. It is believed that depression precedes acceptance because it represents a healthy beginning in truly taking in the negative aspects of one's disability. Finally, acceptance takes many forms for different people, but it usually indicates some integration of the loss into one's life. In this circumstance, acceptance may mean having all the negative feelings about one's hearing loss while not letting those feelings interfere with relationships and daily life. When going through the stages of mourning, functioning may be affected over the short term, but the person usually will move toward some degree of acceptance. If they do not, they may need emotional support from either a therapist or a support group. The Psychology of Cochlear Implants Personality and psychological factors can affect the surgical outcome in cochlear implantation. Professionals working with cochlear implants acknowledge a great deal of variation in satisfaction and performance with implants. Some of the factors that affect outcome—which is traditionally measured by speech-recognition ability—include length of deafness, IQ, speechreading ability, and hearing ability before implant. Research also notes certain psychological factors that can affect outcome, such as an individual's point of view (pessimist/optimist), expectations (realistic/non-realistic), and type of support system. There is a dearth of literature on the relationship between personality and cochlear implant surgery outcome. Personality can be thought of as the complex total of who we are, how we think, how we perceive information, and how we interact with the world. Cochlear implant surgery is a life event that will interact with and be shaped by our personality. The way an individual responds to stressful situations, illness, and physical stress in general will predict, to a certain extent, how that individual responds to an implant. Thus, a person who is rigid and pessimistic may look for, and comment on, all of the bad things about an implant, regardless of how it functions. While it may be healthier for an individual to observe the implant as part of a long process and to feel positive, it is very difficult to change the way people evaluate the world. Most people adapt in their own way over time. If they do not, they may benefit from talking with a therapist. People with hearing loss also are affected by a society that values physical perfection and beauty. There is an often subtle and unconscious bias about people who wear hearing aids and cochlear implants. In general, these prejudices are not mean-spirited, but the expression of fear—a fear of facing some of the bad things that can happen to people in life. People tend to want to feel good all the time and do not welcome exposure to things like disability, illness, and death. People often want to avoid exposure to situations and individuals who remind them of these concepts. Try having a conversation about death and dying at your next family gathering and watch the room clear out. This is simply a psychological fact of life, and professionals need to be aware of it. Speech-language pathologists and audiologists can benefit from a collegial relationship with a therapist that works with patients with hearing loss. We often present small group lectures at clinicians' request to encourage clients to understand the emotional effects of hearing loss. One of the goals of good psychotherapy is to help individuals understand how their personality works so they can observe it in operation and see how it affects their point of view. Finally, professionals working with clients with hearing loss must always pay attention to the many variables of hearing loss. The important ones include when the individual became hearing impaired, the cause and degree of the loss, and the progressive nature of the loss (gradual or sudden). The more severe the loss, and the earlier the age at which it was acquired, the greater the impact can be on psychological development. When working with individuals with hearing loss, it is imperative to establish a dialogue that invites information about the history and nature of the loss. The onset and degree of hearing loss make for a diverse group. This diversity can create an identity crisis for individuals who are neither "hearing "nor "Deaf "as they find where they fit in society. Professionals must have a go od grasp of both the physical realities of the individuals' hearing loss (degree, cause, course) as well as where individuals feel they belong on the cultural continuum of hearing loss. Many of these issues are common and can be present in individuals with hearing loss without necessarily being problematic. Whether or not they rise to the level of being a problem is determined by a complex combination of personality and environment. Clinicians can become more empathic listeners and more effective providers when they are educated about these generalities and the specifics of their clients' hearing loss. This includes both physical and psychological information. In the end, the latter will often affect how the client uses the physical information and assistance offered to them. References Niparko J.K., et al. (2000). Cochlear implants: Principles & practices.: Philadelphia, PA: Lippincott Williams & Wilkins. Google Scholar Kubler-Ross E. (1997). On death and dying. Riverside, NJ: Simon & Schuster. Google Scholar Chartrand Max S. (1990). Hearing instrument counseling.: Livonia, MI: National Institute for Hearing Instruments Studies. Google Scholar Vernon M., &Andrews J. (1990). The psychology of deafness. New York, NY: Longman. Google Scholar Author Notes Mary Kaland, is a clinical psychologist in private practice in New York City. She was born with a moderate progressive sensorineural hearing loss that resulted in profound hearing loss in early adulthood. She received a cochlear implant in August 2000. Contact her by email at [email protected] Kate Salvatore, is a fourth-year psychiatry resident at the University of Pennsylvania in Philadelphia. She will graduate in June and will begin a two-year fellowship in child/adolescent psychiatry at Children's Hospital of Philadelphia. She was born with a combined severe-to-profound sensorineural hearing loss in both ears and received a cochlear implant in January 2002. Contact her by email at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 7Issue 5March 2002 Get Permissions Add to your Mendeley library History Published in print: Mar 1, 2002 Metrics Downloaded 25,383 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2002 American Speech-Language-Hearing AssociationLoading ...

Hearing impairment, the most prevalent sensory deficit, affects more than 466 million people worldwide (WHO). We presently lack causative treatment for the most common form, sensorineural hearing impairment; hearing aids and cochlear implants (CI) remain the only means of hearing restoration. We engaged with CI users to learn about their expectations and their willingness to collaborate with health care professionals on establishing novel therapies. We summarize upcoming CI innovations, gene therapies, and regenerative approaches and evaluate the chances for clinical translation of these novel strategies. We conclude that there remains an unmet medical need for improving hearing restoration and that we are likely to witness the clinical translation of gene therapy and major CI innovations within this decade.

On the basis of strong research, universal newborn screening should be performed before age 1 month with repeat or follow-up testing for those who do not pass performed before age 3 months and intervention started before age 6 months. On the basis of strong research and consensus statement, tympanostomy tubes should be considered for individuals with bilateral persistent middle ear effusion for 3 months or greater and a documented conductive hearing loss. On the basis of consensus statement, all children with suspected hearing loss should have an age appropriate hearing test. On the basis of strong research, the most common form of congenital hearing loss is genetic. Most of this is nonsyndromic hearing loss.

Emotional expressions are very important in social interactions. Children with cochlear implants can have voice emotion recognition deficits due to device limitations. Mandarin-speaking children with cochlear implants may face greater challenges than those speaking nontonal languages; the pitch information is not well preserved in cochlear implants, and such children could benefit from child-directed speech, which carries more exaggerated distinctive acoustic cues for different emotions. This study investigated voice emotion recognition, using both adult-directed and child-directed materials, in Mandarin-speaking children with cochlear implants compared with normal hearing peers. The authors hypothesized that both the children with cochlear implants and those with normal hearing would perform better with child-directed materials than with adult-directed materials. Thirty children (7.17-17 years of age) with cochlear implants and 27 children with normal hearing (6.92-17.08 years of age) were recruited in this study. Participants completed a nonverbal reasoning test, speech recognition tests, and a voice emotion recognition task. Children with cochlear implants over the age of 10 years also completed the Chinese version of the Nijmegen Cochlear Implant Questionnaire to evaluate the health-related quality of life. The voice emotion recognition task was a five-alternative, forced-choice paradigm, which contains sentences spoken with five emotions (happy, angry, sad, scared, and neutral) in a child-directed or adult-directed manner. Acoustic analyses showed substantial variations across emotions in all materials, mainly on measures of mean fundamental frequency and fundamental frequency range. Mandarin-speaking children with cochlear implants displayed a significantly poorer performance than normal hearing peers in voice emotion perception tasks, regardless of whether the performance is measured in accuracy scores, Hu value, or reaction time. Children with cochlear implants and children with normal hearing were mainly affected by the mean fundamental frequency in speech emotion recognition tasks. Chronological age had a significant effect on speech emotion recognition in children with normal hearing; however, there was no significant correlation between chronological age and accuracy scores in speech emotion recognition in children with implants. Significant effects of specific emotion and test materials (better performance with child-directed materials) in both groups of children were observed. Among the children with cochlear implants, age at implantation, percentage scores of nonverbal intelligence quotient test, and sentence recognition threshold in quiet could predict recognition performance in both accuracy scores and Hu values. Time wearing cochlear implant could predict reaction time in emotion perception tasks among children with cochlear implants. No correlation was observed between the accuracy score in voice emotion perception and the self-reported scores of health-related quality of life; however, the latter were significantly correlated with speech recognition skills among Mandarin-speaking children with cochlear implants. Mandarin-speaking children with cochlear implants could have significant deficits in voice emotion recognition tasks compared with their normally hearing peers and can benefit from the exaggerated prosody of child-directed speech. The effects of age at cochlear implantation, speech and language development, and cognition could play an important role in voice emotion perception by Mandarin-speaking children with cochlear implants.

Background: Sensory loss may lead to intra- and cross-modal cortical reorganization. Previous research showed a significant correlation between the cross-modal contribution of the right auditory cortex to visual evoked potentials (VEP) and speech perception in cochlear implant (CI) users with prelingual hearing loss (HL), but not in those with postlingual HL. The present study aimed to explore the cortical reorganization induced by postlingual HL, particularly in the right temporal region, and how it correlates with speech perception outcome with a CI. Material and Methods: A total of 53 adult participants were divided into two groups according to hearing ability: 35 had normal hearing (NH) (mean age = 62.10 years (±7.48)) and 18 had profound postlingual HL (mean age = 63.78 years (±8.44)). VEPs, using a 29-channel electroencephalogram (EEG) system, were recorded preoperatively in the 18 patients scheduled for cochlear implantation and in 35 NH adults who served as the control group. Amplitudes and latencies of the P100, N100, and P200 components were analyzed across frontal, temporal, and occipital areas and compared between NH and HL subjects using repeated measures ANOVA. For the HL group, speech perception in quiet was assessed at 6 and 12 months of CI use. Results: No difference was found in amplitudes or latencies of the P100, N100, and P200 VEP components between the NH and HL groups. Further analysis using Spearman correlations between preoperative amplitudes and latencies of the P100, N100, and P200 VEP components at the right temporal electrode position T8 and postoperative speech perception showed that the HL group had either significantly higher or significantly lower amplitudes of the P200 component at the right temporal electrode position T8 compared to the NH controls. The HL subgroup with higher amplitudes had better speech perception than the subgroup with lower amplitudes at 6 months and 12 months of CI use. Conclusions: Preoperative evaluation of cortical plasticity can reveal plasticity profiles, which might help to better predict postoperative speech outcomes and adapt the rehabilitation regimen after CI activation. Further research is needed to understand the susceptibility of each component to cross-modal reorganization and their specific contribution to outcome prediction.