RUNNING HEAD: Early Implantation and Expressive Language

Early Implantation and Expressive Language Amanda Hook LING 4P27 Research Paper For: Barbra Zupan Due: Friday, November 19th 2010

There has been much debate between the deaf community and the hearing community over cochlear implantation. Regardless, with the implementation of the infant hearing program which provides hearing screenings at birth, we have been able to identify and diagnose children with hearing impairments earlier than ever. This ability to identify and diagnose children so young has led doctors and audiologist to a world of new possibilities. Although there has been much debate over whether cochlear implantation should be provided to deaf children or not, there has been extensive research done to prove why implantation will lead to significantly beneficial outcomes. During the film Sound and Fury, a deaf family investigates the idea of a cochlear implant for their daughter Heather. Heathers mother initially feels it would be best if she herself were to receive a cochlear implant before she made the decision to implant her child. During this investigation, Heathers mother was told that if she were implanted she would be able to hear and understand speech to some degree but would likely not develop any intelligible spoken language. She was told that if her daughter Heather were implanted, however, she would have a better chance at developing expressive language because she was still so young. With that said, although there are many positive consequences to implanting a child early, the confines of this paper will explore the relationship between early implantation and the development of expressive language; in which we will find a positive correlation between early implantation and the development of expressive language. It will be necessary to briefly explore each side of this debate and look at reasons why someone would want to implant there child or not. By exploring the deaf culture and looking a bit deeper at individual motives for implants we can understand why such a heated debate still occurs today, regardless of technological advances. Whether an individual decides to implant their child is up to them, however, families should keep in mind that the earlier we implant a child the greater the outcome. It is believed that there is a critical

period of neural development that aid in the success of cochlear implants (Hammes, Novak, Rotz, Willis, Edmondson & Thomas, 2002). With that said, in order for a child to gain optimal benefits in relation to normal spoken language, early implantation is necessary. This paper will be twofold. Initially we will look at the differences in expressive language between children who are implanted early in relation to children who are implanted later in life. By looking at these differences we will be able to conclude that early implantation is much more beneficial than waiting to implant a child. Once a general conclusion is made from the latter it will be significant to investigate the development of expressive language in children with cochlear implants in relation to the development of expressive language in hearing children. Children who are implanted at a young age will significantly outscore children who are implanted later in life on expressive vocabulary tests and will develop age-appropriate spoken language. The documentary film Sound and Fury provides us with a strong insight into the continuous debate between the deaf world and the hearing world in relation to cochlear implants. While it is easy for those with normal hearing to say cochlear implantation is what is best for children, those of the deaf world often disagree. As demonstrated in the film, those of the deaf culture feel that being deaf is not a disability, rather, it allows deaf people to form a bond and share common morals and values. The deaf world often feels threatened by our society, as it has always aimed at preventing disabilities and inequalities, and thus has looked for ways to eliminate this form of human disparity (Lane, Hoffmeister & Bahan 1996). It is important to stress that those of the hearing world are not necessarily implanting children to extinguish the deaf culture; rather they are implanting children to allow for optimal chances at language development. Through extensive research it will be understood that this is not simply a matter of opinion, rather, there is hard evidence as to why early implantation is beneficial in relation to expressive language development.

Many studies have been done on expressive language development in deaf children based on age of cochlear implantation. Hammes, Novak, Rotz, Willis, Edmondson & Thomas (2002) conducted a study to determine the importance of early implantation. Four age groups were looked at in terms of initial implantation. These groups consisted of implantation at 9-18 months (12 children in total), 19-30 months (13 children total), 31-40 months (11 children) and 41-48 months (11 children). Each group was similar in terms of age of identification, hearing loss, cause of hearing loss and cognitive levels. The length of cochlear implant use ranged from one month to nine years of age. Spoken language measures were all standardized with the exception of one test and they were all normalized on hearing children. Spoken language measures were determined based on the childs age, attention span, and overall ability levels. This study tended to focus on the use of spoken language; more specifically, whether or not spoken language was the primary mode of communication after implantation. All children used total communication before being implanted regardless of the age of implantation. Results indicated that after implantation the children implanted early relied primarily on spoken communication. Although all children after implantation made a transition to spoken language, the results differed in terms of how often they used spoken language. Of the children who were implanted between the ages of 19 and 30 months, six of them relied solely on spoken language while the other seven children of this group used it situationally. When looking at the results of the older age groups we see that the majority of children who were implanted between 31 and 40 months and 41 and 48 months relied heavily on sign language for communication. These results indicate that early implantation positively correlates with using expressive language as a primary mode of communication. It can also be assumed that early implantation leads to better expressive language development since we see that children who are implanted early on rely on spoken

language as a primary means of communication (Hammes, et al. 2002). An interesting finding within this study was found among a participant who had been using his cochlear implant for nine years in total. It was found that even though this participant had used his cochlear implant for a long period of time, because he was implanted later in life he still relied solely on sign language as a primary means of communication. This finding suggests that it is not duration of use that accounts for expressive language acquisition but rather age of implantation. A similar study was conducted by Manrique, Cervera-Paz, Huarte & Molina (2004a). This study analyzed speech production in two groups of children; one group were implanted at the age of two years or younger, and the other group of children were implanted between the ages of two and six. Both groups of children were reported having a profound, congenital, bilateral hearing loss. The group of children who were implanted under the age of two consisted of 36 participants and the group of children implanted between the ages of two and six consisted of 94 participants. It was found that children who were implanted earlier (before the age of two) scored higher on the Peabody Language Development test than the children who were implanted later (between the ages of two and six). This particular study proves that those children who are implanted earlier develop better expressive language than those implanted later. This study also relates to the second part of this paper, that is comparing implanted children with normal hearing children. The Peabody Language Development Test correlates ones chronological age and the age of vocabulary acquisition based on normal development. This is a standardized test that is used on normally developing children with normal hearing. The children that were implanted under the age of two followed a relatively normal development of language in comparison to normal developing children with normal hearing. Those implanted later showed more of a delay in expressive language development when compared to the normal trend. More specifically,

children who were implanted before the age of two showed a slight delay when compared to the normal baseline - a delay of approximately one year. However, children implanted between the ages of two and six showed a more drastic delay in relation to the baseline of development; a delay of approximately three years (Manrique et al., 2004a). This study is significant in the fact that it addresses the two distinct questions we are examining. Firstly, it addresses whether children who are implanted early develop better expressive vocabulary than children implanted later and secondly, it addresses whether early implantation leads to a better chance of normal development. These results conclude that children, who are implanted early, preferably before the age of two, will score better on expressive language tests and develop relatively normal expressive language skills when compared to those implanted later. A second study was conducted by these same researchers in 2004. This study, much like the latter, wanted to analyze the relationship between age and long-term auditory results, including that of expressive language abilities (Manrique, Cervera-Paz, Huarte & Molina, 2004b). Not much detail of this study will be addressed as it is extremely similar to the study previously mentioned. Regardless of the similarity, it is significant to examine due to the fact that we can make more generalized conclusions about whether or not there is a positive correlation between early implantation and spoken language development. Results of this study indeed find a positive correlation between these two variables. It was found that the children of this study who were implanted between the ages of 0 and 3 years developed normal acquisition of vocabulary. Children who were implanted between the ages of 4 and 6 years showed an approximate three year delay when compared with the normal baseline. Children who were implanted after the age of 6 scored significantly poorer than the children implanted between the ages 4 and 6. The results of both studies conducted by Manrique et al. (2004) indicate a common

trend; early implantation leads to normative language development. We can see that the later you implant a child the less chance that child has of reaching normal language development. Although the previous study indicated normal development in terms of expressive language if implanted early enough, not all studies examined thus far have found this. For example, the first study looked at by Manrique et al (2004a) found that there was a slight delay in expressive vocabulary even if implanted at an early age. It is crucial to further explore whether these children with slight delays will eventually catch up to their normal hearing peers. In order to find this out we must look at longitudinal studies. A study done in 2007 by Nicholas and Geers examine this exact question. The purpose of this study was to determine if an oral education program after receiving a cochlear implant would eventually lead to the development of normal expressive language skills. Two groups were analyzed in this particular study; children implanted between their first and third birthday and a reference group of children with normal hearing. Much like the previous studies mentioned, this study wanted to initially find out if early implantation had an effect on expressive language growth. Indeed, it was found that early implantation led to a significantly higher language level. Children who were implanted between the ages of 12 and 18 months scored consistently higher on spoken language tests than those who received an implant at an older age. Although this particular study addressed many different questions, one major relevant question for this paper is will these children catch up, that is, will they reach normal expressive language levels eventually? This study concluded that children who are implanted before the age of 24 months who take part in oral education can be expected to exhibit levels of spoken language that are on par with hearing age-mates before they enter kindergarten (Nicholas & Geers, 2007, p.1060). This here proves that children who are implanted earlier have a better chance of exhibiting normal language in preschool than those children who are implanted as late as three years old.

We can then expect that these children receiving cochlear implants before the age of twenty-four months will develop appropriate spoken language skills. These spoken language skills can then account for a smooth, successful transition into a mainstream classroom system just in time for kindergarten (Nicholas & Geers, 2007). A more recent study done in 2010 by Ona Wie discovered similar results in relation to whether or not children will catch up in terms of expressive language development. This study was considered one of the only studies conducted that looked at the development of childrens speech and language over a long period of time. The goal of this study was to examine language development in prelingually deaf children with cochlear implants and track their progression over time. The sample consisted of 21 profoundly, prelingually deaf children and a reference group of 21 normal hearing children. Each child in the prelingually deaf group had received bilateral cochlear implants between the ages of 5 and 18 months. It is important to note that the children from each group were matched based on chronological age and not hearing age at the point of testing. The expressive language tests that were conducted focused on speaking ability of the children and language formation. Once children were implanted they were seen for check-up appointments after 3, 6, 9, 12, 18, 24, 36 and 48 months. Results indicated that the mean scores of cochlear implant users at the 3 through 48 month check ups were lower than that of the normal hearing children. The greatest difference was found between the checkups of 9 through 36 months. These scores were approximately minus one standard deviation from the mean score of normal hearing children. The 48 month check up however, indicated that there was no significant difference in test scores between cochlear implant users and children with normal hearing. The study indicates that overall 57% of implanted children developed expressive language within the 12-48 month range. Although this appears to be a relatively small number it is important to remember that these children were scored based on their chronological age. If we were to score

these children based on their hearing age, results would indicate that they actually have a very fast pace of language development. When looking at the 48 month check-up appointment, we can see that the child have reached the same level of his or her chronologically aged peers. This then suggests that when compared to normal hearing children of the same chronological age, a delay in spoken language may only occur for the first 36 months but that the child will eventually be able to catch up to the normative level. We can assume that these findings are applicable to those children who are implanted under the age of 18 months (Wie, 2010). Children implanted later in life will likely take longer to catch up based on previous research indicated in this paper. Longitudinal research on this topic is significant due to its findings. We can see that it may be easy to assume that children with cochlear implants will be delayed in comparison to their normal hearing peers but in reality, when implanted early enough, children can reach the normative level for expressive language. Thus far, we have analyzed numerous studies and concluded that there is a positive correlation between early implantation and expressive language development in children. What then, does this particular finding suggest? It seems to suggest that there is a critical period in which neural development occurs. Robinson (1998) found that although there may not be one single critical period, there are a number of critical periods of language acquisition. With that said, even if a child is implanted after what linguist Eric Lenneberg considers being a critical period for language development; children will still be able to develop some skills. The studies analyzed throughout this paper tend to suggest that sensory activity leads to development in the brain that is crucial for expressive language. When a lack of sensory activity occurs there may be a loss of responsiveness thus affecting normal development of expressive language (Robinson, 1998). When a child is implanted this lack of stimuli is reversed. The concept of developmental plasticity leads us to believe that children who are implanted at a younger age will likely perform

better on expressive language tests. Although a deprivation of sensory activity leads to a loss of responsiveness to some degree, if children are implanted young enough, preferably before the age of two, the auditory system has the capacity to catch up with the normal development baseline (Robinson, 1998). When looking back at our original statement that children who are implanted at a young age will significantly outscore children who are implanted later in life on expressive vocabulary tests and will develop age-appropriate spoken language, we have seen that multiple research analysis prove this to be true. It can be said then, that in the movie Sound and Fury it would be realistic to assume that Heather would develop more intelligible expressive language skills in comparison to her mother. Although her mother would benefit to some degree with a cochlear implant, individuals who are looking into pursuing implants must have realistic expectations of the probable outcomes post-implantation. Although there is no age at which a cochlear implant is discouraged, it is important to understand that a child implanted earlier in life (preferably before the age of 2) will develop better expressive language skills and most likely reach a normative language level before kindergarten.

References Hammes, M. D., Novak, A. M., Rotz, L., Willis, M., Edmondson, M. D., & Thomas, F. J. (2002). Early identification and cochlear implantation: Critical factors for spoken language development. Annals of Otology, Rhinology & laryngology, 111, 74-78. Lane, H, Hoffmeister, R, & Bahan, B. (1996). A journey into the deaf-world. San Diego, California: DawnSignPress. Manrique, M., Cervera-Paz, F., Huarte, A., & Molina, M. (2004a). Advantages of cochlear implantation in prelingual deaf children before 2 years of age when compared with later implantation. The Laryngoscope, 1462-1469. Manrique, M., Cervera-Paz, F., Huarte, A., & Molina, M. (2004b). Prospective long-term auditory results of cochlear implantation in prelinguistically deafened children: The importance of early implantation. Acta Otolaryngol, 552, 55-63. Nicholas, G. J. & Geers, E. A. (2007). Will they catch up? The role of age at cochlear implantation in the spoken language development of children with severe to profound hearing loss. Journal of Speech, Language, and Hearing Research, 50, 1048-1062. Robinson, K. (1998). Implications of developmental plasticity for the language acquisition of deaf children with cochlear implants. International Journal of Paediatric Otohinolaryngology, 46, 71-80. Weisberg, R (Producer), Roth, J. (Coordinating Producer) & Aronson, J (Director). (2000). Sound and Fury [Motion Picture]: United States of America: A Production of Aronson Film Associates and Public Policy Productions. Wie, B. O. (2010). Language development in children after receiving bilateral cochlear implants between 5 and 18 months. International Journal of Paediatric Otorhinolaryngology, 74, 1258-1266.